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Application For Special Order For Graduation

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NIR QA Form 5

REPUBLIC OF THE PHILIPPINES


DEPARTMENT OF EDUCATION
NEGROS ISLAND REGION

PROCESSING SHEET
APPLICATION FOR ISSUANCE OF SPECIAL ORDER FOR GRADUATION

Name of School : _____________________________________________________


Address of School : _____________________________________________________
Subject/s Offered : _____________________________________________________
School Year : _____________________________________________________
Date Received : _____________________________________________________

Particulars Quality Description Remarks


1. Processing Sheet  Duly accomplished and signed by the Division
In-charge of private/public schools and
countersigned by the ASDS and SGOD Chief
2. Endorsement  Duly signed by the SDS or his/her appointed
OIC
 Dated within one week prior to submission to
RO
3.Form 9  Duly Accomplished Form with the Name
of the Students, Course and Academic
Year Graduated
 Name of the Regional Director is also
printed.
4.Letter of  . Letter of Recommendation from the
Recommendation School registrar/Principal or the
Committee for Checking of Documents of
the Candidates for graduation of the
Particular Year;
 List of Names of All Student-Recipients of
Certificates and Diplomas;

5.Form 137  Certified True Copy of the Secondary


(Student Permanent Student’s Permanent Record of the last
Record) school attended
 Certified true Copy of the Secondary
Student’s Permanent Record of the latter
school, if the student is a transferee from
another school;
 Certification from the School
Registrar/School Principal if the student is
taking summer classes to another school
or a cross-enrollee of another school;

6.Birth Certificate  Verified Copy of the Original NSO/PSA Birth


Certificate from the PSA or certified true copy

QAD Form for Application of Special Order for Graduation Page 1


NIR QA Form 5

for Filipino Citizen students, if the student is


not a Filipino citizen, submit copies of the birth
certificate from a foreign country, alien
certification of registration;
7.Evaluation Form  Accomplished Student Evaluation Form with
signatures of the School
Registrar/Principal/Administrator and the
Division Supervisor-in-Charge of Private
Schools.

Evaluated by: Counterchecked by:


___________________ _______________________________
Division In-charge Chief, SGOD
Noted:
____________________________
ASDS

Reviewed and validated by: Checked and verified:

CYNTHIA M. VISPERAS/RONAMIE V. RELIQUIAS SOFIA A. TUNDAG


QAD Asst. Lead Coordinators Regional QAD Lead Coordinator

Remarks:
 Approved: ____________
 Returned /With deficiencies: ______

QAD Form for Application of Special Order for Graduation Page 2

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