EASTERN VISAYAS STATE UNIVERSITY

Tacloban City
Control No. EVSU-SASO-F-055
Revision No. 1
Title of Form: EVSU Admission Form Application Form
Date Feb. 24, 2020

M-20-1-00387-0241
Application Number

I. PERSONAL INFORMATION (To be filled in by APPLICANT)

A. Personal Data
Name: FLORES HONEY ALBERTYNNE
Surname First Name Middle Name Name Extension

Sex FEMALE Civil Status SINGLE Nationality FILIPINO Religion ROMAN CATHOLIC

Date of Birth (yyyy-mm-dd) 2001-12-10 Place of Birth TACLOBAN, CITY Age 18

Permanent Address 10744177 COLAWEN

House/Block/Lot No./Street/Subdivision/Village Barangay
PASTRANA LEYTE 6514
Town/City/Municipality Province Zip Code

Phone 09150541616 Email kimbertynne@gmail.com

Do you have any disability? [X] NO [_] Yes, please specify

B. Family Background
Father's Name PETILLA ALBERTO PASAGUI Age 48
Surname First Name Middle Name Name Extension

Mother's Maiden Name FLORES MA. NENA NOVIO Age 40

Surname First Name Middle Name Name Extension

If Married,
Age
provide your spouse's full name
Surname First Name Middle Name Name Extension

Is your family a beneficiary of 4Ps? [_] No [X] Yes, please provide the DSWD Household Number Average Monthly Household Income 5000

C. Educational Background
Curriculum: [_] ALS [_] BEC [X] SENIOR HIGH SCHOOL TRACK: HUMSS
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School PASTRANA CENTRAL SCHOOL 2014 121825070058
High School JUAN VILLABLANCA MEMORIAL HIGH SCHOOL 2018 121825070058
Senior High School JUAN VILLABLANCA MEMORIAL HIGH SCHOOL 2020 121825070058
College

By signing below, I certify that above information are correct and true and that I give my consent to the collection and processing of my personal data in accordance with the needs and requirements of
the university.

HONEY ALBERTYNNE FLORES

Signature over printed name of the Applicant
II. INTERVIEW (To be filled in by INTERVIEWER)
First Choice Second Choice Third Choice
Campus Preferred Course Campus Course Applied Campus Course Applied
MAIN CAMPUS Tacloban BSA TANAUAN CAMPUS BSIT BURAUEN CAMPUS BSE ENGLISH

Criteria Personality Communication Skill Reading Skill

Rating

Average Rating To get the average, add earned points and divide by 3

Potential/Talent/ 1 2 3 4 5
Special Skills

Add-on Point: One (1) point will be earned for every potential /talent/special skill
Total Points: Average Rating + Add-on Points

Signature over printed name of the Interviewer

III. EXAMINATION PERMIT (To be filled in by OGS)

Application No.:
M-20-1-00387-0241
Name: HONEY ALBERTYNNE FLORES
Course Applied: BSA
Examinee No.:
Date of Interview: Wed, Mar 4, 2020 1:00 PM
Date of Examination: Fri, Mar 6, 2020 1:00 PM
Testing Room TANAUAN CAMPUS - ROOM 1

Office of the Guidance Services

Downloaded By: HONEY ALBERTYNNE FLORES , Mon, Feb 24, 2020 6:38 PM