Republic of the Philippines

Department of Education
Region 02 (Cagayan Valley)
SCHOOLS DIVISION OFFICE OF ISABELA
Alibagu, City of Ilagan, Isabela 3300

ICTU-TAF-02 ICT EXTERNAL TECHNICAL ASSISTANCE (TA) FORM

CLIENT INFORMATION For DepED Email Password Creation/Reset,
School ID:30058 Pls fill this up: Emp. No.0005536
School Name:SALINUNGAN NATIONAL HIGH SCHOOL First Name: DEBYLYN
District:SAN MATEO NORTH Middle Name: PASCUAL
School Head: JULIETA M. DOMING, EdD Last Name:CEREZO
Contact No.:09175550277 DepED Email (for Reset): _____________________________
ICT Coordinator:GILBERT C. SORIANO_ Contact No.: 09666428998______
Contact No:09279387155 TIN:412-254-361 Birthdate: 02-18-1982
For DepED LIS/EBEIS User Acct. Mng’t. System: For Internet Connectivity Concern/Issues:
Pls fill this up: Pls fill this up:
Request for Password Reset: Request for TA-Installation:
School Head Username: __________________________ Municipality: __________________________________________
Desired Password: ______________________ Potential Provider: ____________________________________
System Admin Username: __________________________ Request for TA-Existing Subscriber:
Desired Password: ______________________ Status: ( ) Fixed ( ) Portable
Request for Change of School Head: Nature: ( ) Postpaid ( ) Prepaid
Provider: _______________________________
Name of New School Head: ________________________
Average Spending: ____________________
TIN (New School Head): _____________________
Date of Birth: ______________________ Remarks:
Name of Prev. School Head: ________________________ _______________________________________________________
_______________________________________________________
TIN (Prev. School Head): ____________________
_______________________________________________________
Date of Birth: ______________________
DepED Computerization Program (DCP)
DCP Batch No. ________ Date of Delivery: ______________________
Part Code
Number: 2. System Unit
Hardware
5. Peripherals 8. Drivers
Software
11. Update 14. Router/Cables
Network Others
1. Printer 4. Internal 7. OS 10. Installation 13. LAN Configuration
3. Monitor/Display 6. Connectors/Plugs/Power 9. Malware 12. Files/Data 15. Internet

ITEM DESCRIPTION PROBLEM/ISSUE SERIAL NO.

FINDIN (Please identify Part Code Number) (Please specify) (Please refer to your Delivery Receipt)
GS

-----------To be filled up by ICT Unit-----------

STATUS/RECOMMENDATION/REMARKS:

( ) GOOD/RETURNED ( ) CHECK FOR AUTHORIZED SERVICE CENTER ( ) FOR REPLACEMENT ( ) UNSERVICEABLE

OTHER DETAILS:
School Head/Representative: Received/Noted by:
ORLANDO L. NICOLAS, JR.

Signature over Printed Name Information Technology Officer I

Date:_________________________ Date:_________________________
(078) 323-0281 Sdo Isabela Document Code:
(078) 323-2015 https://deped-isabela.com.ph Rev.:
isabela@deped.gov.ph As of: