Education Service Contracting
Application Form
ESC Form 1
ABOUT ME
Learner Reference Number (LRN)
404184150516
Last Name
Doctora
First Name
Lance Elijah
Middle Name
Nakpil
Suffix (i.e. Jr., III) Date of Birth
May 17,2009
Place of Birth
Iloilo City
Nationality Gender
/☐Filipino ☐Others (Specify) /☐Male ☐Female
2x2 ID Photo
ADDRESS AND CONTACT DETAILS
Street Address Barangay/District
Blk 6 Lot 24 Monticello Balabag
Municipality/City Province
Pavia Iloilo
Zip Code Mobile/Landline No. Email Address
5001 09454602032 doctoralance@gmail.com
ABOUT MY FAMILY
First Name Middle Name Last Name Relationship
1 Rommar Latuna Doctora Father
2. Lace Nakpil Doctora Mother
3. Shaun Zachary Nakpil Doctora Brother
4.
5.
6.
Total No. of Siblings
Note: Use back page if more than six family members
2
Does your family own any of the Motorcycle/Pedicab Car, Van, Pick-up or Truck Land or Farm no
following ☐Yes /☐No ☐Yes ☐No ☐Yes ☐No
☐Owned ☐Rented ☐Company Provided/Living with No of Bedrooms
Home details
Relatives
SUPPORT FOR COST OF SCHOOLING
Last Name First Name Sources of Income Gross Monthly Income
☐ Locally Employed
☐ Employed Abroad ☐ Php 0-5,000
☐ Self- ☐ Php 5,001-10,000
employedProfessional ☐ Php 10,001-15,000
Father Doctora Rommar ☐ Self- ☐ Php 15,001-20,000
employedBusiness ☐ Php 20,001-25,000
☐ Php 25,001-50,000
☐ Retired/Unemployed
☐ More than Php50,000
☐ Others: __________
☐ Locally Employed
☐ Employed Abroad ☐ Php 0-5,000
☐ Self- ☐ Php 5,001-10,000
employedProfessiona ☐ Php 10,001-15,000
Mother l ☐ 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
☐ Employed Abroad ☐ Php 0-5,000
☐ Self- ☐ Php 5,001-10,000
employedProfessiona ☐ Php 10,001-15,000
Guardian l ☐ 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
☐ Employed Abroad ☐ Php 0-5,000
☐ Self- ☐ Php 5,001-10,000
Person Helping Send employedProfessiona ☐ Php 10,001-15,000
the Child to School l ☐ Php 15,001-20,000
(If applicable) ☐ Self- ☐ Php 20,001-25,000
employedBusiness ☐ 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
St. Joseph School Inc. School Type ☐Public ☐Private
Province City/Municipality Barangay/District
Iloilo ILoilo Manduriao
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 40,000 5,000 10,000
ATTESTATION
Recent Identical 2x2 ID photo (2 copies)
PSA Certified Birth Certificate
Photocopy of Grade 6 Report Card
Latest Income Tax Return for the previous year or Certificate of Tax
Documents attached to this application 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
Lance Elijah N. Doctora Oct.29, 2021
Signature of Parent/Guardian over printed name Date
Rommar L. Doctora Oct.29,2021
