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

B-22-1-11072-0326
Application Number

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

A. Personal Data
Name: PASTORIL RHEA MALDO
Surname First Name Middle Name Name Extension

Sex FEMALE Civil Status SINGLE Nationality PILIPINO Religion ROMAN CATHOLIC

Date of Birth (yyyy-mm-dd) 2004-02-23 Place of Birth BURAUEN DISTRICT HOSPITAL Age 18

Permanent Address ZONE 7 DITA

House/Block/Lot No./Street/Subdivision/Village Barangay
JULITA LEYTE 5606
Town/City/Municipality Province Zip Code

Phone +639925462245 Email rheapastoril23@gmail.com

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

B. Family Background
Father's Name PASTORIL BENJAMIN LUNGAY SR. Age 49
Surname First Name Middle Name Name Extension

Mother's Maiden Name MALDO DOLORES MALQUISTO Age 46

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 0027 Average Monthly Household Income 3500

C. Educational Background
Curriculum: [_] ALS [_] BEC [X] SENIOR HIGH SCHOOL TRACK: GAS
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School DITA ELEMENTARY SCHOOL 2016 121523090017
High School JULITA NATIONAL HIGH SCHOOL 2020 121523090017
Senior High School
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.

RHEA M. PASTORIL
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
BURAUEN CAMPUS BSOA MAIN CAMPUS Tacloban BSHM TANAUAN CAMPUS BSOA

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.:
B-22-1-11072-0326
Name: RHEA M. PASTORIL

Course Applied: BSOA

Date of Interview:

Date of Examination:

Testing Room

Office of the Guidance Services

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