Disclosure: By accomplishing this Verification/COR Request Form, the applicant hereby consents to the collection, processing and storing

storing of personal data by the

Bureau of Education Assessment for the exclusive purpose of facilitating the transaction that he/she requested.

Republic of the Philippines

Department of Education
BUREAU OF EDUCATION ASSESSMENT

VERIFICATION / COR REQUEST FORM

Please check one and specity the relevant testing program:

Verification of Test Result

REQUEST FOR: TESTING PROGRAM:
Second copy of COR
Purpose of Request:

Surname First Name MI

Name
of the
Learner
Contact No. Age Sex
Home Address:
M F
Date of Birth Email Address Date of Examination

Name of School/Examination Center School I.D.

Address of School/Examination Center Region Division

I hereby declare under oath that I have personally accomplished this Verification/COR Request Form and that by affixing my name below, I am certifying that all documents
attached to this application is a faithful reproduction of the original, and that all statements and information provided therein are complete, true and correct to the best of my
knowledge. I am assuming full responsibility and accountability on the corectness of the details provided and authenticity of the documents submitted. I am aware that any
violation will automatically disqualify me and authorize the Bureau of Education Assessment to deny the transaction I applied for and forfeit payments rendered thereof.

PRINTED NAME OF APPLICANT

INSTRUCTIONS TO THE REQUESTING PARTY AUTHORIZATION:

Fill-out all necessary information in the boxes highlighted in gray. Do not leave
any details blank. Write NA if not applicable. This is to authorize the person stated below to transact and settle application
Strictly follow the instructions/procedures posted. Fill out the Google Form and shipping payments on my behalf:
through the link provided and attach this form in MS Excel Format along with a
scanned copy of your supporting documents .
Expect an email from BEA indicating the verification findings and details of
release of the document requested.
Wait for the shipping of the document to your mailing address.
Name of Authorized Representative

ORDER OF PAYMENT FORM

Name: . Date March 15, 2021
In payment for: Qty Amount
Verification/ COR Request 1 50.00
0 -
-
-
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TOTAL AMOUNT PHP 50.00