BE Form 04

DEPARTMENT OF EDUCATION

STATEMENT OF INTERESTS

Name & Signature:

Name of Company/Organizations:

Address:

Telephone/CP No.:

Contact Person

Contact of Public School/s: UPPER PULACAN ELEMENTARY SCHOOL

Form of Intervention: (Choose any of the two or both)

A. Donation in kind for: (Please Check the desired donation)

____1. Repair of Desk/Chairs/tables ____2. Repair of HE Ceiling____ 3. Repair of School Canteen ____4. Repair of door/window jams____5. Repainting of Roofing (back of 5 bldgs.) ____ 6. Repainting of concrete perimeter fence____7. Repainting of Front Walls ____8. Repainting of window/door jams____9. Repainting of desks/chairs/tables ____10. Repainting of HE ceiling____11. Enhancing of landscaping ____12. Cleaning the school ground/gardens____13. Tapping electric connection to (2) DepEd/DPWH Comfort Rooms____14. Concreting of entrance garage

Specific Materials / donations to be given

B. Volunteer Man-days/Labor SupportNature of Volunteer Services Time and Date/s of Availability

Please submit filled-out form to the principal of the school that you plan to help

HON. JESUS L. DAOALABarangay Chairman Upper PulacanChairman BE Resource Mobilization CommitteeLENIE P. MARQUEZSchool Principal

Thank you very much!