Education Service Contracting
Application Form
ESC Form 1
ABOUT ME
Learner Reference Number (LRN)
441090150244
Last Name
OCTAVIO
First Name
JOHN ROLAND
Middle Name
LOPEZ
Suffix (i.e. Jr., III) Date of Birth
JUNE 17, 2004
Place of Birth
BACOLOD CITY
Nationality Gender
✓ Filipino ☐Others (Specify) ✓Male ☐Female
ADDRESS AND CONTACT DETAILS
Street Address Barangay/District
BLK. 9, LOT 22. DC-3 RPHS ALIJIS
Municipality/City Province
BACOLOD CITY NEGROS OCCIDENTAL
Zip Code Mobile/Landline No. Email Address
6100 09476265181 / 034-432-7090 johnrlnd1704@gmail.com
ABOUT MY FAMILY
First Name Middle Name Last Name Relationship
1. ROLANDO MAGPAYO OCTAVIO FATHER
2. EVELYN LOPEZ OCTAVIO MOTHER
3. JACOB ORVEL LOPEZ OCTAVIO BROTHER
Total No. of Siblings
Note: Use back page if more than six family members
1
Does your family own any of the Motorcycle/Pedicab Car, Van, Pick-up or Truck
Land or Farm
following ☐Yes ☐No ✓Yes ☐No ☐Yes ☐No
No of Bedrooms
Home details ✓Owned ☐Rented ☐Company Provided/Living with Relatives 2
SUPPORT FOR COST OF SCHOOLING
Last Name First Name Sources of Income Gross Monthly Income
☐ Locally Employed
☐ Php 0-5,000
☐ Employed Abroad
☐ Php 5,001-10,000
☐ Self-employed-
☐ Php 10,001-15,000
Professional
Father ROLANDO ☐ Php 15,001-20,000
OCTAVIO ☐ Self-employed-
☐ Php 20,001-25,000
Business
☐ Php 25,001-50,000
☐ Retired/Unemployed
☐ More than Php50,000
✓Others: no work
✓ Locally Employed ☐ Php 0-5,000
☐ Employed Abroad ☐ Php 5,001-10,000
☐ Self-employed- ✓ Php 10,001-15,000
Mother OCTAVIO EVELYN Professional
☐ Php 15,001-20,000
☐ Self-employed-
☐ Php 20,001-25,000
Business
☐ Php 25,001-50,000
☐ Retired/Unemployed
☐ More than Php50,000
☐ Others:
☐ Locally Employed
☐ Php 0-5,000
☐ Employed Abroad
☐ Php 5,001-10,000
☐ Self-employed-
☐ Php 10,001-15,000
Professional
Guardian N.A N.A ☐ Php 15,001-20,000
☐ Self-employed-
☐ Php 20,001-25,000
Business
☐ Php 25,001-50,000
☐ Retired/Unemployed
☐ More than Php50,000
☐ Others:
☐ Locally Employed
☐ Php 0-5,000
☐ Employed Abroad
☐ Php 5,001-10,000
☐ Self-employed-
Person Helping Send ☐ Php 10,001-15,000
Professional
the Child to School N.A N.A ☐ Php 15,001-20,000
☐ Self-employed-
(If applicable) ☐ Php 20,001-25,000
Business
☐ Php 25,001-50,000
☐ Retired/Unemployed
☐ More than Php50,000
☐ Others:
*For employees, it refers to the gross monthly salaries and wages before taxes and other deductions. It includes basic pay,
overtime pay, commissions, tips, allowances and one-twelfth of annual bonuses. For all others, it refers to the average monthly
earnings from their business, trade, profession, investments and/or pensions.
ABOUT MY ELEMENTARY SCHOOL
Name of Elementary School
EVANGELICAL CHRISTIAN MONTESSORI SCHOOL School Type ☐Public ✓ Private
Province City/Municipality Barangay/District
NEGROS OCCIDENTAL BACOLOD CITY ALIJIS
If the Elementary School is Private, please indicate the school fees charged by the Elementary School.
Level Tuition (Php) Other (Php) Miscellaneous (Php)
Grade 6 N.A Php 3,500.00
Php 1,200.00/ Monthly
ATTESTATION
Recent Identical 2x2 ID photo (2 copies)
PSA Certified Birth Certificate
Photocopy of Grade 6 Report Card
Documents attached to this application
Latest Income Tax Return for the previous year or Certificate of Tax
Exemption or Municipal Certification of Unemployment of Parents/Legal
Guardian
I certify that my answers are true and correct to the best of my knowledge.
I am aware that the information supplied in this form will be retained by PEAC on a database and will be processed in compliance
with the Data Protection Act of 2012.
I consent that the information herein may be used for reports both internally and to the Department of Education.
Signature of Student over printed name Date
JOHN ROLAND L. OCTAVIO JANUARY 14, 2021
Signature of Parent/Guardian over printed name Date
EVELYN L. OCTAVIO JANUARY 14, 2021
