This document appears to be from a Chilean school named Colegio San Cristobal, located on Av. Diego Portales in Santiago, Chile. It requests the name, date, and class of the recipient, likely for a student assignment or record.
Passive voice COLEGIO SAN CRISTOBAL
Av. Diego Portales N° 1.520.
La Florida Fono: 4268729
Santiago
Name:___________________________ Date:__________ Class:____________