PRE-ENLISTMENT FORM FOR IRREGULAR STUDENTS (COECSA)

Privacy Notice

In Lyceum of the Philippines University, we value your privacy and aim to uphold the same when processing your personal data.

For purposes of the request/application of Pre-Enlistment for Irregular Students (COECSA) within this pandemic, we may collect basic information about you such as your
name, contact number, email address and enrolment/registration details.

We are committed to protecting your personal data from loss, misuse, and any unauthorized processing activities, and will take all reasonable precautions to safeguard its
security and confidentiality. Your academic data will be kept permanently by our Records Section. Neither will we disclose, share, or transfer the same to any third party
without your consent.

We recognize your rights with respect to your personal data. Should you wish to exercise any of them or if you have any concerns regarding our processing activities, you may
contact us privacy.cavite@lpu.edu.ph

Thank you.

INSTRUCTIONS
1. Please fill-out the form properly based on the preferred request/application.
2. Submit this form to https://forms.office.com/r/wBN0fP61n1
3. All request/application are subject for review and approval.

STUDENT AND APPLICATION DETAILS

Student Name: (SN, FN, MI) Caluban, Kim Alester B. Date: August 13, 2021
Student No. : 2018-2-03372 Semester/AY: 1st Semester/ AY 2021-2022
Program/Year Level: BSME/5th Year Email Address: caluban25@gmail.com

SECTION SUBJECT CODE UNITS

ME 501 MELL03E 2
ME 501 PSTL01E 1
ME 501 CAML01E 3

TOTAL UNITS

CONSENT
By filling out and submitting this electronic form online, I hereby acknowledge and certify that I have carefully read and understand the terms and conditions of the Data Privacy Policy of the Lyceum of the Philippines University (LPU). By providing
personal information to LPU, I am confirming that the data is true and correct. I understand that LPU reserves the right to revise any decision made on the basis of the information I provided should the information be found to be untrue or
incorrect. I likewise agree that any issue that may rise in connection with the processing of my personal information will be settled amicably with LPU before resorting to appropriate arbitration or court proceedings within the Philippine jurisdiction.
Finally, I am providing my voluntary consent and authorization to LPU and its duly authorized representative to lawfully process my/my child’s data/information.

* This electronic form is for online application purposes only.

--- TO BE FILLED-OUT BY AUTHORIZED PERSONNEL ONLY ---

ENLISTED / FACILITATED BY DATE