Repub*ic cf tfr* pilitippin*s

Departr*ent cf Edr.*cation
Region lV'-A CALABARZSN
f,ity Sahcols *iv*sier: af Cabuy**
City cf eebuya*,
hE\/\DP*F\Du\"\

!i*i : All Adrninistratcrs *f Private SchoolsiC*lleges &

Technical-Vo*atia*al lnstituticns
GiC, Chief, S*h**ls Gcvernance and Operations $ivision
Fublic Schools fi istrict $upervisor
$EPS/EP$ - $chool Managern*nt Mo*itoring and [Link]
Seniar High $chc*l *oordinator
A{{St*ers Cancemed

rR*M
Ql rr ft4./^/
DORIS [Link]
O:C - $+haEls Divisien $uperintendent

$UBJTCT GU{nrLthrF$ sN &{H rs$uAs,{sE 0F $pECfAL sR0Efis rsR T'$-{ffi

APPR*VAL #F TI-IE ELI€;BNI..ITY FSR SRAilTJATISN FRGrS!
$EIUIOR }.*'GI-i $C!{S*LS OF GRAilf; ,t} LEARr{ER$ frNROLLES I$\I
PRIVATf; S*hI*OLSfC*LLryGES & [Link]-VOCATISI'dAL
tNsTlTuT*stus FOR scHs*L yrAR ?01?-e$r&

NATH MARCH $. 2018

Relative to the issued DepEd-4A-RM-G5-18 dated March ?, ZSlg on above

suhje*t, the field is requested t* submit the requirernents to the $cho*ls Divisi**
Office *t
tabuyec ** *r b*fcr* Marcl.: 18, t019.

The follawing ere the requirements tc be subrnitted:

'X. Graduation Fonn
{Fcnn Si
t. Forrn 137 {pr-evicus scl-is*iand current s*h*ol
3. Phot*copy of Govemment permlt {per track, strand, specialization}
4. *irth Certificate {p$A}
5. Summ'er Slass Fermit if*r tit*se sch+*]s whic!: offered $ilr?rrper *!ass)
r *e*ificati*nlreport cerd fsr siudents with sumrner class
S. List af graduating students {hard & soft capy}
" Alphabeti*al: fulale and Female
* Per secticn, track, str*nd, speciali=*tion

For immediate dissemination and *omplian*e"

1. DepEd-4A-RM-S5-13 dated March ?, A01B

2. Template far Grad*ati** F*rn: {Form 9}
3. Template fer $pecial Order

sgoci/p&r'leanr

$^ leL e. to16
 Republic of the Philippines
DEPARTMENT OF EDUCATION Division
Region IV-A CALABARZON Logo
Division of ___________

ATTESTATION
Month Day, Year

DIOSDADO M. SAN ANTONIO

Regional Director
Region IV-A CALABARZON

Thru: EDENIA O. LIBRANDA

OIC, QAD

Whereas, this Office received ALL the required documents stipulated in the Regional
Memorandum DEPED-4A-RM-05-18- from NAME OF SCHOOL, Address of School, for the
issuance of Special Orders for the Approval of the Eligibility for Graduation from Senior
High School of Grade 12 Learners for School Year 2017-2018;

The undersigned, now therefore attest to the VERACITY OF DOCUMENTARY INFORMATION

and COMPLIANCE of the said private school/college/technical-vocational institution to
the requirements of the Department of Education and request that the Regional Office
issue Special Order Numbers for the Grade 12 graduating students.

Attested by:

Signature
NAME OF SGOD CHIEF
SGOD Chief

Recommending Approval:

Signature
NAME OF SCHOOLS DIVISION SUPERINTENDENT
Schools Division Superintendent
 Republic of the Philippines
DEPARTMENT OF EDUCATION
REGION IV-A CALABARZON
Gate 2 Karangalan Village
1900 Cainta, Rizal

January 10, 2018

SPECIAL ORDER (A)

No. ______, s. _______

On the basis of the records submitted by ___________(Name of School)______________________

_____(Address)__________________ approval of the eligibility for completion of Senior High School
(Track: ________________, Strand: ________________, Specialization: ________________) of the following
as of ____(Month, Year)_____ upon the successful completion of the work now being taken in the
____K to 12 Basic Education Program ____ is hereby given and made a matter of record:

1. (LAST NAME, First Name, MI) 6.

2. 7.
3. 8.
9.
4.
10.
5.

Valid for _____number_____ students only.

The foregoing approval is valid only for ________(Month, Year)______. The approval for any
candidate for completion of the Senior High School is automatically cancelled if he does not
complete the full requirements of the course on the date specified, and is subject to revocation if
the records upon which the approval is based are later found not correct.

(NOT VALID WITHOUT SEAL OR WITH For the Secretary of Education,

ERASURE OR ALTERATION)

Enrolment checked by: ____________________

Form 9 checked by: ____________________ DIOSDADO M. SAN ANTONIO
Verified against original: ____________________ Director IV
Evaluated by: ____________________
Checked by: ____________________
Reviewed by: ____________________
Template for STEM FORM 9 (Graduation Form)
LEARNER REFERENCE NO. (LRN): ________________________________
NAME: _______________________________________ DATE OF BIRTH: ______________________ AGE: __________
NAME OF FATHER: _______________________________ MOTHER’S MAIDEN NAME _____________________________
LAST SCHOOL ATTENDED: ___________________________________________ SY: _____________________________
GRADE 11 (FIRST SEMESTER) SY_________________ GRADE 11 (SECOND SEMESTER) SY______________
Final Action No. of Final Action No. of
SUBJECTS Grade Taken Hours SUBJECTS Grade Taken Hours
Core Core
Oral Communication in Context Passed 80 Reading & Writing Skills Passed 80
Komunikasyon at Pananaliksik sa Passed 80 Pagbasa at Pagsusuri ng Iba’t- Passed
Wika at Kulturang Pilipino or Ibang Teksto Tungo sa or 80
Failed Pananaliksik Failed
General Mathematics 80 Statistics & Probability 80
Disaster Readiness & Risk
Earth Science 80 Reduction 80
Introduction to the Philosophy of Personal Development/
the Human Person 80 Pansariling Kaunlaran 80
Physical Education & Health 20 Physical Education & Health 20
Contextualized & Specialization Contextualized & Specialization
Empowerment Technologies: ICT 80 Research in Daily Life I 80
for Professional Tracks
Pre-Calculus 80 Basic Calculus 80
General Chemistry 1 80
Total 580 Total 660

GRADE 12 (FIRST SEMESTER) SY_________________ GRADE 12 (SECOND SEMESTER) SY_____________

Final Action Hours Grade Action Hours
SUBJECTS Grade Taken SUBJECTS Taken
Core Core
21st Century Literature from the Passed/ 80 Physical Education & Health Passed/ 20
Philippines & the World Failed Failed
Contemporary Philippine Arts 80 Contextualized & Specialization
from the Regions
Media & Information Literacy 80 Research in Daily Life 2 80
Understanding Culture, Society 80 Entrepreneurship 80
and Politics
Physical Education & Health 20 Research Project 80
Contextualized & Specialization General Physics 2 80
English for Academic and 80 General Biology 2 80
Professional Purposes
Pagsulat sa Filipino sa Piling 80 General Chemistry 2 80
Larangan (Akademik)
General Physics 1 80 Research/Capstone Project 80
General Biology 1 80
Total 660 Total 580

Summer ______________ Summer _____________

SUBJECTS Final Gr. Action Hours SUBJECTS Final Gr. Action Hours

Classified as Grade 12, School Year

School:

Core Subjects 15 = 1,200 hours I hereby certify that this is a true record of
Contextualized 7 = 560 hours
Specialization 9 = 720 hours
Total 31 = 2,480 hours As per requirement of the Dep-Ed. He/She is eligible for graduation in 20

Checked & Evaluated by: Date NAME

Principal/Administrator
____________________________________
(EPS In-Charge of Private School)
Template for TVL: HE FORM 9 (Graduation Form)
LEARNER REFERENCE NO. (LRN): _________________________
NAME: _________________________________ DATE OF BIRTH: ______________________ AGE: -__ __________
NAME OF FATHER: _____________________ MOTHER’S MAIDEN NAME:________________________
LAST SCHOOL ATTENDED: _________________________________________ SY: _____________________________

GRADE 11 (FIRST SEMESTER) SY ___________________ GRADE 11 (SECOND SEMESTER) SY __________________

Final Action No. of Final Action No. of
SUBJECTS Grade Taken Hours SUBJECTS Grade Taken Hours
Core Core
Oral Communication in Passed 80 Reading & Writing Skills Passed 80
Context
Komunikasyon at Pananaliksik Passed 80 Pagbasa at Pagsusuri ng Iba’t-Ibang Passed
sa Wika at Kulturang Pilipino or Teksto Tungo sa Pananaliksik or 80
Failed Failed
General Mathematics 80 21st Century Literature from the 80
Philippines and the World
Personal Development / Understanding Culture, Society and
Pansariling Kaunlaran 80 Politics 80
Physical Education and Health Statistics & Probability
20 80
Contextualized & Physical Education & Health 20
Specialization
English for Academic and 80 Contextualized & Specialization
Professional Purposes
Filipino sa Piling Larangan 80 Practical Research 1 80
(Tech-Voc)
Tour Guiding Services (NC II) 80 Tour Guiding Services ( NC II) 80

Bread and Pastry Production 80 Bread and Pastry Production 80

(NC II) (NC II)
Total 660 660

GRADE 12 (FIRST SEMESTER) SY_________________ GRADE 12 (SECOND SEMESTER) SY _________________

Final Action Hours Grade Action Hours

SUBJECTS Grade Taken SUBJECTS Taken
Core Core
Earth and Life Science Passed/ 80 Physical Science Passed/ 80
Failed Failed
Introduction to the Philosophy of 80 Physical Education & Health 20
the Human Person
Contemporary Philippine Arts 80 Contextualized &
from the Regions Specialization
Media and Information Literacy 80 Empowerment Technologies 80
(for Tech-Voc)
Physical Education & Health 20 Entrepreneurship 80
Contextualized & Specialization Inquiries, Investigation and Immersion 80
Practical Research 2 80 Tourism Promotion Services (NC II) 80

Tourism Promotion Services (NC 80 Food and Beverages Services 80

II) ( NC II)
Food and Beverages Services 80 Work Immersion 80
( NC II)

Total 660 Total 660

Summer: ____________ Summer: ___________

SUBJECTS Final Gr. Action Hours SUBJECTS Final Gr. Action Hours

Classified as Grade 12, Sch. Yr.

Core Subjects 15 = 1,200 hours
Contextualized 7 = 560 hours School:
Specialization 9 = 720 hours I hereby certify that this is a true record of
Total 31 = 2,480 hours
As per requirement of the Dep-Ed. He/She is eligible for graduation in 20
Checked & Evaluated by:
Date NAME
______________________________ Principal / Administrator
(EPS, In-Charge of Private Schools)
 Republic of the Philippines
Department of Educaticn
REGION IV-A CALABARZON
Gate ? Karangalan Village
190S Cainta, Rizal

DEPTD-4A-3&{-05-rS- lq
IG SUFERINTEHDEilT$

rROM

SUB.'ECT GUIDETINES ON THE ISSUANCE OT SPTSAL ORDERS FOR THE APPROVAL

OF THE ELIGIBILITY FOR GRADUATION FNOM SENIOR HIG}I SCHOOL CIF
GRADE I?LEARHERS TNROLLFD IN P*IVATT SCHOOLS/COIIEGES &
TECH [Link] I NSTITUTIONS FOR SCHOOL Y EAR 201 7.20 I 8

DATE Itjlcrrch 7.2018

t. Fursuant 1o Depld Order No. I0. s.2018. dated ft{arch 5,20,l8, "Guidelines on
the lssucnce of Specicl Orders for ihe Approvcl of the Eligibiiiiy lcr Grcduslion
from Senior High Schaal of Grode l2 Lecrners Fnrolied in Privcfe Schools/Colleges
ond Technicol-Vocotionol lnstituiions {TVls} for School Yeor 20'17-2018". The
Regioncl Office {RO} is qufhorized to issue special orders lc scho*ls th*t were
lssued provisioncl permils io opercle in SY 20.} 6-20"l7 cr prior to lhls school yecr
for ihe groduation of qualifiecl Grsde l2 iearners.

L Due lo iime constrcints ond considering the number of Senior High Schools in the
Regian, ihe evcluction and validctian of dccurnenis shsli be done at the
Schools Divisi*n Cffices {SDOs}.

3. The following cre the requiremenls io be submitted io the Division Office by the
Private SchoolslColleges and Techniccl-Vocniional ins'liiutions {TVis) :

o Gradu*iion Form {Form ?}

-137
o Form {previous schocl snd curenl schooli
o PhclCIcopy of Government Permit {per lrock, strsnd, specializction}
a Birtrh Certificaie {PSA}
o Surnmer Class Permit {for lhose schools which offered summer classJ
n Cerf ificciionlrepori cord, for students with summer clcrss
{) Lisi of graduoting students {hard & sofi copy}
r Alphabeticcl: Male cnd Femcle
. Per section, irsck, strsnd, specializotion

re
Trunk Line: {02} SS2-5773 / 684-4914 I 64?-7487
Fax: {il2} 6Sl-2114
Wetrsite: depedcalaba rzon. ph
i&#i
i-#i
Facebookr DepEd R-4A Calabarzon
F-ari!" r*i:nnA:iljidsha,4 ,rrv n!:
iAJA|
lla*qf,s
DE?ED-4A-RM-05-18- Ig1 Page 2 of 2

4. Applicctions for Speciol Orden of quolified Grode l2leorners for SY 2017-2018

sholl be filed by the school through the Schools Division Office {SDOI st leqst l5
colendar doys before the end of ihe cunent ocodemic yeor.

5. Upon evoluoiion ond vslidotion of the Division Office ihe following documenis
cre lo be submiited to the Regionol Oltice:

o Lisiof Groduaiing Students {hord ond sofi copyi

o Per section: lrack, strond, speciolizalion
o Grcdusiion Form iForm 9)
o Atiestotion bv ihe SDO

6. Enclosures io lhis Regionol Memorsndum ore Templcte for Groduclion Form

{Form I for STEM ond TVL) ond templote for Specicl Order snd Formst of
Attestction by the SDO.

7. lmmedicte qnd wide disseminotion ol the Memorcndum is desired.

Template for TVL: HE FORM 9 (Graduation Form)
LEARNER REFERENCE NO. (LRN): _________________________
NAME: _________________________________ DATE OF BIRTH: ______________________ AGE: -__ __________
NAME OF FATHER: _____________________ MOTHER’S MAIDEN NAME:________________________
LAST SCHOOL ATTENDED: _________________________________________ SY: _____________________________

GRADE 11 (FIRST SEMESTER) SY ___________________ GRADE 11 (SECOND SEMESTER) SY __________________

Final Action No. of Final Action No. of
SUBJECTS Grade Taken Hours SUBJECTS Grade Taken Hours
Core Core
Oral Communication in Passed 80 Reading & Writing Skills Passed 80
Context
Komunikasyon at Pananaliksik Passed 80 Pagbasa at Pagsusuri ng Iba’t-Ibang Passed
sa Wika at Kulturang Pilipino or Teksto Tungo sa Pananaliksik or 80
Failed Failed
General Mathematics 80 21st Century Literature from the 80
Philippines and the World
Personal Development / Understanding Culture, Society and
Pansariling Kaunlaran 80 Politics 80
Physical Education and Health Statistics & Probability
20 80
Contextualized & Physical Education & Health 20
Specialization
English for Academic and 80 Contextualized & Specialization
Professional Purposes
Filipino sa Piling Larangan 80 Practical Research 1 80
(Tech-Voc)
Tour Guiding Services (NC II) 80 Tour Guiding Services ( NC II) 80

Bread and Pastry Production 80 Bread and Pastry Production 80

(NC II) (NC II)
Total 660 660

GRADE 12 (FIRST SEMESTER) SY_________________ GRADE 12 (SECOND SEMESTER) SY _________________

Final Action Hours Grade Action Hours

SUBJECTS Grade Taken SUBJECTS Taken
Core Core
Earth and Life Science Passed/ 80 Physical Science Passed/ 80
Failed Failed
Introduction to the Philosophy of 80 Physical Education & Health 20
the Human Person
Contemporary Philippine Arts 80 Contextualized &
from the Regions Specialization
Media and Information Literacy 80 Empowerment Technologies 80
(for Tech-Voc)
Physical Education & Health 20 Entrepreneurship 80
Contextualized & Specialization Inquiries, Investigation and Immersion 80
Practical Research 2 80 Tourism Promotion Services (NC II) 80

Tourism Promotion Services (NC 80 Food and Beverages Services 80

II) ( NC II)
Food and Beverages Services 80 Work Immersion 80
( NC II)

Total 660 Total 660

Summer: ____________ Summer: ___________

SUBJECTS Final Gr. Action Hours SUBJECTS Final Gr. Action Hours

Classified as Grade 12, Sch. Yr.

Core Subjects 15 = 1,200 hours
Contextualized 7 = 560 hours School:
Specialization 9 = 720 hours I hereby certify that this is a true record of
Total 31 = 2,480 hours
As per requirement of the Dep-Ed. He/She is eligible for graduation in 20
Checked & Evaluated by:
Date NAME
______________________________ Principal / Administrator
(EPS, In-Charge of Private Schools)
Template for STEM FORM 9 (Graduation Form)
LEARNER REFERENCE NO. (LRN): ________________________________
NAME: _______________________________________ DATE OF BIRTH: ______________________ AGE: __________
NAME OF FATHER: _______________________________ MOTHER’S MAIDEN NAME _____________________________
LAST SCHOOL ATTENDED: ___________________________________________ SY: _____________________________
GRADE 11 (FIRST SEMESTER) SY_________________ GRADE 11 (SECOND SEMESTER) SY______________
Final Action No. of Final Action No. of
SUBJECTS Grade Taken Hours SUBJECTS Grade Taken Hours
Core Core
Oral Communication in Context Passed 80 Reading & Writing Skills Passed 80
Komunikasyon at Pananaliksik sa Passed 80 Pagbasa at Pagsusuri ng Iba’t- Passed
Wika at Kulturang Pilipino or Ibang Teksto Tungo sa or 80
Failed Pananaliksik Failed
General Mathematics 80 Statistics & Probability 80
Disaster Readiness & Risk
Earth Science 80 Reduction 80
Introduction to the Philosophy of Personal Development/
the Human Person 80 Pansariling Kaunlaran 80
Physical Education & Health 20 Physical Education & Health 20
Contextualized & Specialization Contextualized & Specialization
Empowerment Technologies: ICT 80 Research in Daily Life I 80
for Professional Tracks
Pre-Calculus 80 Basic Calculus 80
General Chemistry 1 80
Total 580 Total 660

GRADE 12 (FIRST SEMESTER) SY_________________ GRADE 12 (SECOND SEMESTER) SY_____________

Final Action Hours Grade Action Hours
SUBJECTS Grade Taken SUBJECTS Taken
Core Core
21st Century Literature from the Passed/ 80 Physical Education & Health Passed/ 20
Philippines & the World Failed Failed
Contemporary Philippine Arts 80 Contextualized & Specialization
from the Regions
Media & Information Literacy 80 Research in Daily Life 2 80
Understanding Culture, Society 80 Entrepreneurship 80
and Politics
Physical Education & Health 20 Research Project 80
Contextualized & Specialization General Physics 2 80
English for Academic and 80 General Biology 2 80
Professional Purposes
Pagsulat sa Filipino sa Piling 80 General Chemistry 2 80
Larangan (Akademik)
General Physics 1 80 Research/Capstone Project 80
General Biology 1 80
Total 660 Total 580

Summer ______________ Summer _____________

SUBJECTS Final Gr. Action Hours SUBJECTS Final Gr. Action Hours

Classified as Grade 12, School Year

School:

Core Subjects 15 = 1,200 hours I hereby certify that this is a true record of
Contextualized 7 = 560 hours
Specialization 9 = 720 hours
Total 31 = 2,480 hours As per requirement of the Dep-Ed. He/She is eligible for graduation in 20

Checked & Evaluated by: Date NAME

Principal/Administrator
____________________________________
(EPS In-Charge of Private School)
 Republic of the Philippines
DTPARTMT!{T OF EDUCATIO}T
REGIOIT T1I-A CALABANZ{'!g
Gate 2 Karangalan Village
19OO Cainta. Rizal

.l0,2018
Jcnuory

SPECTAL ORDER {Al

No, . s.

On the basis of the records submitied by {Ntrme of School}

fAddress) cpprovol of the eligibility lor complelion ol Senior High School
{Trock: Slrond: Specializoiion: ) of the following
os of ft\fonth, Yeqr) upon the successful compleiion of the work now being tsken in ihe
K fo 12 Bcsic Educolion Protrrom is hereby given cnd msde s motler of record:

1 (LAST NAillE. First Narne. Ml) 6.

-f
2.
o
3.
A
tt I
(

Valid for number students oniy.

The loregoing opprovcl is valid cnly fcr fMonili. Yecrl . The opprovcl for cny
ccndidote for completion of the Senior High Schocl is outornoticclly cancefled if he does noi
complete the fullrequiremenis of the course on fhe daie specified. snd is [Link] to revocction if
ihe reccrds upon which ihe cpproval is bcsed are later found not coneci.

(NOT VALTD ITSTHOUT SrAt OR W|TH For the Secreicry of Educslion,

ERASURE OR ALTERATTON]

Enrolment checked by:

Form I checked by: DIOSDADO M. SAN ANTONIO
Verified ogcinst origincl: Direclor lV
Evoluoied by:
Checked by:
Reviewed by:
 Republic of the Philippines

imj
""t:*% DEPARTMENT OF EDUCATION
Region lV-A CALABARZON
Division of

ATTESTATION
Month Doy, Yeor

DIOSDADO M. SAN ANTONIO

Regionol Director
Region lV-A CALABARZON

Thru: EDENIA O. LIBRANDA

OIC, QAD

Whereos, this Office received AIL ihe required documents stipuloted in the Regionol
Memorondum DEPED-4A-RM-05-.l8- from NAME OF SCHOOI, Address of School, forihe
issuonce of Speciol Orders for the Approvol of the Eligibility for Groduoiion from Senior
High School of Grode l2 Leorners for School Yeor 201 7-2A18:

The undersigned, now therefore ottest to ihe VERACITY OF DOCUMENTARY INFORMATION

ond COMPTIANCE of the soid privote school/college/technicol-vocotionol institution to
the requiremenis of ihe Deportment of Educotion ond request ihot the Regionol Office
issue Speciol Order Numbers for the Grode l2 groduoting students.

Attested by:

Signoture
NAME OT SGOD CHIEF
SGOD Chief

Recommending Approvol :

Signoture
NAME OF SCHOOTS DIVISION SUPERINTENDENT
Schools Division Superintendent