DATE RECEIVED BY CICT:

APPLICATION FORM
______________________

Please indicate (mark with an “x) the organization initiating the set-up of an eSkwela Center:
DepED LGU NGO Civic Org Other If other, please      
specify:

If DepED initiated, please Region       Name      

indicate the following: ALS Division, District       Position      
Location of potential site       Contact Office /      
(please indicate exact Person (for Organization
address eSkwela
If Non-DepED initiated, Name of Organization       setup and Telephone      
please indicate the following: Location of proposed site       this form)
(please indicate exact Email      
address)

Target Date of eSkwela Operations:       AVAILABILITY OF INFRASTRUCTURE REQUIREMENTS

Space/Room
*Please provide pictures of the proposed site (interior and exterior), computers and
Target Number of OSYAs for first batch      
equipment (if already available) by attaching it to this form (if RAF will be sent via courier) or
of eSkwela learners:
via email ( cict.eskwela@gmail.com )
Schedule of eSkwela sessions (Please mark Airconditioning Tables and
Specifications Room Size Electricity
planned operating hours and days with an “X”) Units Chairs
AM M T W Th F Sat Sun electric outlets 3-10 computers:
one set (computer
should be enough for 1 aircon (2
8:00 – 9:00 At least 1.5 sqm per number of computers horsepower)
table and chair)
9:00 – 10:00 per computer, plus
computer, with and Center
Required 2 additional sets
10:00 – 11:00 provision for work equipment; separate 11 computers or
for Center
area circuit breakers for more:
11:00 – 12:00 computers and 2 aircon units (2
Manager and
PM Learning Facilitator
aircon units horsepower)
1:00 – 2:00
2:00 – 3:00
3:00 – 4:00
Actual (please
4:00 – 5:00
indicate actual                        
5:00 – 6:00
specs)
6:00 – 7:00
7:00 – 8:00
8:00 – 9:00

If yes, what Dial-up DSL /

Computers Yes No Internet Yes No type (mark x) Broadband
If yes, indicate
service If Broadband,
How many?       provider:       What speed?      
Computer Specs - General
 Yes No
Do the computers run on Windows?
(if yes, please indicate version – Windows 98, 2000, XP or Vista)
Can you play audio (CDs, mp3s) in the computers?
Can you play video (VCDs, DVDs) in the computers?
Are the computer units networked? (with LAN cables or wireless)
Computer Specs - Detailed
You may ask the resident IT/computer expert in your office (Network Administrator, MIS, programmer):
Internet /
Network - Software*
Technical How many Performance Multimedia Capability Ready
Specs computer units?
Hard Sound Operating
Processor Memory Disk Card Video Card Monitor Headset LAN Card System Applications
Any
160 GB Higher than licensed / licensed /
2.4 GHZ Any, Any,
1 server PC 2 GB (w/ <10 GB 1024 x 768 LCD 10/100 Mbps open source open souce
& higher working working
free space) resolution operating applications
system
Recommended
Any
Any,
80 GB Higher than licensed / licensed /
20 900 MHZ or Any, working (1
512 MB (w/ <10 GB 1024 x 768 LCD 10/100 Mbps open source open souce
workstation PCs equivalent working headset per
free space) resolution operating applications
computer)
system
Any
80 GB licensed / licensed /
900 MHZ or Any, 1024 x 768 Any,
1 server PC 1 GB (w/ 10 GB CRT 10/100 Mbps open source open souce
equivalent working resolution working
free space) operating applications
system
Minimum
Any
4 Any,
40 GB licensed / licensed /
computer 500 MHZ or Any, 1024 x 768 working (1
256 MB (w/ 10 GB CRT 10/100 Mbps open source open souce
units equivalent working resolution headset per
free space) operating applications
(including server) computer)
system
                                                           
1 server PC
Actual (please
indicate actual                                                                  
computer specs workstation PCs
here; use extra (indicate how many)
rows if needed)                                                                  

* (please send photos of license stickers of proprietary operating system/applications; on a separate sheet, please also indicate license/serial number/s of
OS/applications. Please send photos and license/serial number list to cict.eskwela@gmail.com)
AVAILABILITY OF STAFF REQUIREMENTS
Center Manager Network Administrator
Name            
Office / Organization            
Please indicate relevant experience (educational background, work            
experience, training)
Learning Facilitators
How Many?      
Relevant Experience (yes or no)
Trained in ALS? Computer user? / Does he make use Does he/she make use of the
Name Position / Designation
(If Yes, please indicate of the computer for routinary tasks Internet (e.g. e-mail, browsing,
date of training) (e.g. reports, letters, etc)? chat)?
1.                             
2.                             
3.                             
4.                             
5.                             
Community Involvement
Please indicate (mark with an “X”) the involvement of your community in the implementation of eSkwela How can eSkwela, as a project, serve your
(please specify for NGO, Civic Org, or Other): organization, your community and its out-of-
Civic Other school youth and adults?
DepED LGU NGO Org
Provision of Space/Room for eSkwela            
Renovation of space/room (if needed)      
Electricity      
Internet      
Airconditioning Units      
Headsets      
Computer Tables and Chairs      
Supplies (print modules – for modules where      
eSkwela e-modules are not yet available;
materials for learner portfolio)
Computers      
License for OS (if proprietary; i.e. Windows)      
Repair and Maintenance of computers      
Center Manager, salary      
Network Administrator, salary      
Learning Facilitators, salary      

Accomplished by:       Noted by:      

(Name & Signature) (Name & Signature of Immediate
Superior / Head of Organization)
Position/ Designation:       Position/ Designation:      
           
Contact Number/s: Contact Number/s:
E-mail Address:       E-mail Address:      
revised as of 3 August 2009