Republic of the Philippines

Department of Education
Region V – Bicol
Schools Division Office of Camarines Norte
Sarah Jane Ferrer High School
Guinacutan, Vinzons, Camarines Norte

PROJECT PEDAL
BIKE LOAN APPLICATION FORM

Name: ___________________________________________________Age:______________

Address: ___________________________________________________________________

Grade Level: __________________________________________Section:_______________

Father’s Name: __________________________________Occupation: _________________

Other Source of Income: ___________________Monthly Income of the Family: _________

Do you collect water for drinking? ___Yes___No Do you use wood for cooking?___Yes__No

A 4Ps Beneficiary? ___Yes___No Do you have loans? ___Yes___No Amount of loan _____

Distance from the School: ___________________Time Spent Going to School: ___________

Knows How to Bike? ___Yes ___No If No, Willing to be Trained? ___Yes ___No

Other Activities to be Used of Bicycle: ____________________________________________

No. of Siblings: _______

Name of Siblings Age Grade Level & Section

_______________________________ _____ _________________________

_______________________________ _____ _________________________

_______________________________ _____ _________________________

_______________________________ _____ _________________________

_______________________________ _____ _________________________

_______________________________ _____ _________________________

_______________________________ _____ _________________________

_______________________________ _____ _________________________

_________________________________ _______________________________
Applicant’s Signature Over Printed Name Parent’s Signature Over Printed Name

Endorsed by: Approved by:

MARK JIM M. TORERO WENEFREDO A. RUBIO, Ed.D.
Bike Coordinator School Head

Sarah Jane Ferrer High School

Brgy. Guinacutan, Vinzons, Camarines Norte
sarahjane.ferrerhs@gmail.com