Document No.

WVSU-ALU-SOI-01-F01
ALUMNI MEMBERSHIP
Issue No. 1
FORM
Revision No. 3
Date of Effectivity: March 4, 2022
WEST VISAYAS STATE Issued by: ALUMNI OFFICE
UNIVERSITY
Page No. Page 1 of 1

Type of Application: Type of Membership

□ Renewal □ Regular ID No. ____________
□ Replacement □ Lifetime Date: _____________ 1x1
□ Lost □ Honorary ID Picture
□ Damaged/faded □ Associate
Personal Information: (Kindly Print)

Name _________________________, _______________ ________________

Family Name First Name Middle Name

Married Name _________________________, _______________ ________________

(For female only) Family Name First Name Middle Name

_________________________, _______________ ________________

Name of Spouse
Family Name First Name Middle Name
Year Graduated Course
Gender Civil Status
Date of Birth Place of Birth
E-mail Address Facebook Account
Address (local) Contact No./Mobile No.
Address (Abroad) Contact No./Mobile No.
Occupation Position
Monthly Salary
Company Name
Company Address
Telephone No
Educational Background:
Year Honors
Name of School Address
Graduated Received
Elementary
Secondary (JHS)
Senior High Sch.
Tertiary
Post Baccalaureate
Graduate School
Alumni Chapter: (Please Check)
Elementary Secondary (Junior High School) Senior High School
Tertiary Post Baccalaureate Graduate School
External

ACKNOWLEDGMENT AND CONFORMITY AGREEMENT

Received Alumni ID with ID No: from WVSU-_________ Campus Alumni Association Inc., If I lost this card due to my
negligence, I promise to immediately report and agree to pay for its replacement fee in the amount of (Php ) together with
Affidavit of lost. The data provided in this form shall be treated with utmost confidentiality and shall be used strictly for alumni affairs purposes
only.

_____________________________________ ________________________________
Signature over Printed Name Date Received
Privacy Notice: Privacy Notice:
This personal information in this document shall be used for the Alumni Personal Ang personal na impormasyon sa dokumentong ito ay para sa APDS
Data Sheet (APDS) only. Any information herein may not be used for other purposes. lamang. Anumang impormasyon ay hindi maaaring gamitin sa ibang
layunin.
 ENTITLEMENTS OF LIFETIME MEMBERS

All LIFETIME MEMBERS of WVSUFAA, Inc. are considered ACTIVE upon payment of the
membership fee of ₱500.00 for LIFETIME. The following are the entitlements of LIFETIME
members upon presentation of the Membership Card:

1. A permanent ID card for Lifetime Members.

2. Entry to the school premises
3. Access to the Learning Resource Center
4. Receive issues of Alumni Newsletter
5. Avail of hospitalization benefits at the WVSU Medical Center
(BOR Resolution No. 99B-2006 & No. 16-2008)
5.1 Room accommodation for a maximum of 30 days in a year – 5%
5.2 OPD Diagnostic Procedure – Service Rate at the Out-Patient Department
6. Ten percent (10%) discount at the University Staff House in Manila
(BOR Resolution No.76 – A – 2010)

Address:
934-C Marian Town Homes, Leon Guinto, Paris St.
Malate, Manila Tel. No. (02) 522-41-50

7. Thirty percent (30%) discount at the University Hometel, WVSU Main Campus
(BOR Resolution No. 76 – B – 2010)
8. Access to the Alumni database/directory
9. Have the right to vote and be voted upon in the Alumni Elections.
10. Avail of the services of the Review Center, and courses offered by the Extension Office.
11. Avail of the services of the University Printing Press, Cultural Center, audio-Visual Room (AVR)
Rehearsal Room and the Drop-in Center.
12. Use of the Alumni Center (Balay sang Alumni) for meetings and /or small gatherings subject to
schedule availability.

For further inquiries, please visit the Alumni Center, WVSU Main Campus.

For Payment:

1. GCash
a. Gcash Name: Jon Athan Glorial
b. Gcash Number: 09171101938

2. Bank Account
a. Account Name: WVSU Alumni Association, Inc.
b. Account Number: 487-3-4875014-69

Dr. Jonathan C. Glorial

Director, Alumni Affairs