Republic of the Philippines

Department of Education
NATIONAL CAPITAL REGION
DIVISION OF CALOOCAN CITY
SAMARIA SENIOR HIGH SCHOOL
Bukid Area, Bo. Sto. Cristo, Brgy. 187, Caloocan City
AR FORM 9 - Principal’s Lister Award
AC FORM 9-2021

PRINCIPAL’S LISTER NOMINATION FORM

The award for Principal’s Lister is given to learners in Senior High School who have
demonstrated exemplary outstanding performance based on the terms of reference or
engagement set by the school and evaluation of the class adviser.

To qualify for this award, a learner must have received high efficiency rating for their
diligence and consistency in performing their duties and responsibilities throughout the
school year.

Only learners who have received an outstanding academic rating 98-100% in the
general average shall be awarded. This rating in the report card consists of the learner’s
performance and/or output during the school year 2023-2024.

Nominee:____________________________________________________
Surname First Name M.I.
2 x 2 picture with
TRACK / STRAND Grade & Section: ___________________________ white background

Class Adviser: _______________________________________________

(Signature over Printed Name)

Nomination form submitted by/Date: __________________________________________

(Signature over Printed Name)

Submit Portfolio as Means of Verification: SF9, SF10, Properly filled-up Nomination

Form

Received by/Date: Checked by/Date:

____________________________________ ___________________________________
(Signature over Printed Name) (Signature over Printed Name)

REMARKS:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Bukid Area, Bo. Sto. Cristo, Caloocan City Eff.
Document No. : AR 9 -PRINCIPAL’S LISTER : 04-24-24
Date
CP No. 09481985540
Email:
Revision No. : 2 Pages : 1 of 1
mariaana.dionisio001@deped.gov.ph
 Republic of the Philippines
Department of Education
NATIONAL CAPITAL REGION
DIVISION OF CALOOCAN CITY
SAMARIA SENIOR HIGH SCHOOL
Bukid Area, Bo. Sto. Cristo, Brgy. 187, Caloocan City
AR FORM 9 - Principal’s Lister Award

Bukid Area, Bo. Sto. Cristo, Caloocan City Eff.

Document No. : AR 9 -PRINCIPAL’S LISTER : 04-24-24
Date
CP No. 09481985540
Email:
Revision No. : 2 Pages : 2 of 1
mariaana.dionisio001@deped.gov.ph