Republic of the Philippines

Department of Education
– Planning Unit
LIS CHANGE REQUEST AND ISSUANCE OF LRN FORM

Control Number: Date:

CLIENT INFORMATION CHANGE REQUEST

Name: Enrolment with gap
Position/Designation: Reason/s for the (pls specify)
School ID and Name:
Contact Number:
E-mail address: Enrolment of ineligible
ISSUANCE OF NEW LRN Erroneously tag EOSY/no status
Name of the learner:
Correct Status:
Section:
Reason for the correction:
Reasons for not having LRN:
1. From accredited/recognized school
School year last attended:
School last attended: Others (pls specify):
2. Undergone catch-up program and assessed
school readiness
Result of the assessment:

3. From not accredited local school

Certification/Accreditation/Equivalency Exam:
a. PEPT Certificate no. _ (For Planning Officer’s use only)
b. PVT Certificate no. _
4. From foreign/Philippine school abroad
Approved Disapproved
School year last attended:
REMARKS/ACTION TAKEN
School last attended:
Country:
5. From ALS
Certification/Accreditation/Equivalency Exam: Date Acted:

a. PEPT Certificate no. _

Received/Acted by:
b. PVT Certificate no. _
6. Others (pls specify)
XYZA C. ZINGAPAN
Planning Officer III

Address: Regional Government Center, Carig Sur, Tuguegarao City, 3500

Telephone Nos.: PLDT (078) 377-1065; Globe Landline (078) 255-5317, (078) 255-5318
Doc Code: FM-SGO-PLA-001 Rev: 00
Email Address: As of: July 2, 2018 Page: 1

Website: