Republic of the Philippines

Eastern Visayas State University - Tanauan Campus

Tanauan, Leyte

FREE HIGHER EDUCATION AND VOLUNTARY CONTRIBUTION FORM

Instruction: Fill in all required information. Do not leave an item blank. If item is not applicable indicate "N/A".

PERSONAL INFORMATION
☐ NEW ENROLLEE ☑ CONTINUING ☐ SHIFTEE ☐ RETURNEE ☐ TRANSFEREE
Learner
Year Level: ☑ 1st ☐ 2nd ☐ 3rd ☐ 4th ☐ 5th Reference 121328080001
Number:
Student Number: 2021-05015 Year & Course: 1st / BSA Sem. & S.Y. 2nd Sem. / 2021-2022
Name: ABAD GLENFORD VELASQUEZ
(Last Name) (First Name) (Middle Name)
Date of Birth: Feb 6, 2003 Place of Birth: Brgy.M.H del Pilar, Dulag, Leyte
Number of Academic
Sex: ☑ Male ☐ Female Units Enrolled:
☑ Single ☐ Married Type of Disability (if
N/A
Civil Status: ☐ Widowed ☐ Separated applicable):
☐ Annuled ☐ Others Indigenous People
N/A
__________ Affiliation (if applicable):
Citizenship: FILIPINO
Father's ABAD PEDRITO ZABALA
Name: (Last Name) (First Name) (Middle Name)

Mother's VELASQUEZ ANALYN AZARCON

Maiden
Name: (Last Name) (First Name) (Middle Name)

N/A DEL PILAR

Permanent (Street Address) (Brgy)
Address: DULAG LEYTE 6505
(City/Mun.) (Province) (Zip Code)
Mobile Number: 09518190306 E-Mail Address: glenabad6@gmail.com

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.

I CERTIFY FURTHER that I am cognizant of and aware of the provisions in RA 10931 (Universal Access to Quality Tertiary
Education Act) and all the benefits and responsibilities under the Act. I voluntarily avail of the Free Higher Education benefits and
privileges and abide with the return service obligation inherent thereto.

☐ I am voluntarily contributing an amount of __________________ (PhP _____) for the academic period 2nd Sem. / 2021-2022.

☑ I am not having my voluntary contribution for the academic period 2nd Sem. / 2021-2022.

GLENFORD ABAD
01-03-2022
_____________________
Name and Signature of Student Date Signed
Conforme:

Analyn Abad 01-03-2022

_____________________
Name and Signature of Parent/Guardian Date Signed

Subscribed and sworn to before me this _______ day of _____________ for purposes of availing the Free Higher Education.

ID No.: _________
____________________________
Issued by: _______
Administering Officer
Issued at: ________

ACKNOWLEDGMENT

This is to acknowledge receipt of the Free Higher Education and Voluntary Contribution Form of GLENFORD ABAD, 1st Year, BSA .

EDERLYN C. DAGAMI, CPA _____________

Registrar Date Signed

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