CHED FORM NO. GPR.

4-A

APPLICATION FOR GOVERNMENT PERMIT/RECOGNITION

TO OPERATE (See below)
FOR SCHOOL YEAR _____________

The Honorable Chairperson Date: ________________

Commission on Higher Education
Office of the President
5th Floor, DAP Bldg., Ortigas Center
San Miguel Ave., Pasig City

Through channels

Sir/Madam:

The undersigned Chairman of the Board of Trustees/President of

__________________________________ at __________________________________
( Name of School ) ( Address of School )

hereby petition for GOVERNMENT PERMIT/RECOGNITION to operate the following

courses under the laws of the Republic of the Philippines.

COURSES CURRICULUM YEAR(S)

__________________________________________ ____________________
__________________________________________ ____________________
__________________________________________ ____________________

To support this petition are the following documents duly certified /

authenticated:

1. Copies of Transfer of Certificate of Title (TCT) / Lease Contract/Ownership of

School Building
2. For additional site(s): copy of TCT, document of ownership and certificate of
occupancy for additional building
3. Feasibility Study to include philosophy and goals, viability, statement of location
of the school, schedule of tuition and other fees
4. Financial statement of the previous year duly certified by an independent
Certificate Public Accountant.
5. Copy of latest tuition fee schedule
6. Copy of latest permit issued by CHED
7. List of school administrators and teaching staff, i. e., President, Vice-President
(s), Deans, Department Heads, to faculty in the GEC and core courses, in
spreadsheet form to include:
a. educational qualification, with certified copy of TOR
b. position / designation
c. nature of appointment (permanent/temporary)
d. status of employment (full-time/part-time)
8. List of Non-Teaching Staff
9. Copy of Retirement Plan duly registered with SEC
10. Curriculum to include distribution of subjects per semester, summary of units,
course description and course syllabi
11. Physical facilities with latest pictures
 12. List of equipments and other instructional devices/aids
13. List of Library Holdings including professional journals
14. List of support facilities (auditorium, sports and recreational, canteen, faculty
lounge, student lounge, dormitories)
15. Inspection fee in the amount of Four Thousand (P4,000.00) per program to be
paid in the Commission on Higher Education CARAGA Regional Office XIII,
Butuan City.

I, as Chairman of the Board / President, promise to maintain the standards required

for this course and to follow faithfully all the laws, the rules and regulations, and the
requirements of the Commission on Higher Education governing the operation of
authorized private school courses and to inform the CHED of any plan or action
regarding closure or phasing out of the course or any changes in the prescribes
requirements. I acknowledge that any violation of the laws , the rules and regulations,
and the requirements of the Commission on Higher Education shall be deemed
sufficient cause for the revocation of the authority granted.

The school will not hold classes in the course applied for above until and unless this
application is approved and the corresponding Government Permit is issued by the
Commission on Higher Education.

Very respectfully yours,

(Chairman of the Board / President)

Republic of the Philippines )

City / Municipality of _____________________ )
Province of _____________________________)

I, __________________________________of the Board of Trustees / President

(Chairman of the Board/President)
of the ________________________________________________ Filipino, of legal age
(School)
and resident of the Philippines, after having been sworn to in accordance with law
depose and say that the information in this application and in the supporting documents
are true and correct.

_______________________________
(Chairman of the Board/President)

SUBSCRIBED AND SWORN to before me this ______ day of ______________

201__. The affiant exhibits his /her Residence Certificate No. ___________________
issued at ___________________________________on ________________________.

_______________________________
(Notary Public)
Doc. No. ___________
Page No.___________
Book No. ___________
Series of ___________