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

data by
Disclosure: 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 Alternative

Learning
X Second copy of COR System
REQUEST TESTING Accreditation
FOR: PROGRAM: and
Equivalency
Test (ALS A &
E TEST)
Purpose of Request:

For College Graduation Requirement

Name Surname First Name MI
of the
Learner CORTINA JULLIAN G.
Home MALVAR, SANTIAGO CITY Contact No. Age Sex
Address:
09555085993 33 M X F

Date of Birth Email Address Date of Examination

JULY 14, 1990 cortinajullian0@gmail.com OCTOBER 2009

Name of School/Examination Center School I.D.

SANTIAGO NORTH CENTRAL SCHOOL N/A

Address of School/Examination Center Region Division

VILLASIS, SANTIAGO CITY 2 DIVISION OF SANTIAGO CITY

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 orrectness 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.

JULLIAN G. CORTINA
PRINTED NAME OF APPLICANT
INSTRUCTIONS TO THE REQUESTING PARTY AUTHORIZATION:

2. Fill-out all necessary information in the boxes highlighted in gray. Do not This is to authorize the person stated below to transact and settle application and
leave any details blank. Write NA if not applicable. shipping payments on my behalf:
3. Strictly follow the instructions/procedures posted. Fill out the Google Form
through the link provided and attach this form in MS Excel Format along
with a scanned copy of your supporting documents . LETICIA G. CORTINA
4. Expect an email from BEA indicating the verification findings and details of Name of Authorized Representative
release of the document requested.
5. Wait for the shipping of the document to your mailing address.
 ORDER OF PAYMENT FORM
Name: . Date May 7, 2024
In payment for: Qty Amount
Verification/ COR Request 1 50.00
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TOTAL AMOUNT PHP 50.00