EVSU-1-ACA-16.037-0002 Application No.

: 2019-
Revision No. 00
2018 Republic of the Philippines
EASTERN VISAYAS STATE UNIVERSITY
Tacloban City
2x2 ID picture

STUDENT AFFAIRS AND SERVICES OFFICE

Office of Guidance Services

EVSU ADMISSION APPLICATION FORM

I. PERSONAL INFORMATION
A. Personal Data
Name:
Surname First Name Middle Name Name Extension

Date of Birth (mm/dd/yyyy) Place of Birth Age

Gender: ( ) Male ( ) Female Civil Status Nationality Religion
Permanent Address
House/Block/Lot No. Street Subdivision/Village Barangay

Town/City/Municipality Province Zip Code

Contact Number: Email Address:

Do you have any disability? ( ) No ( ) Yes, please specify:

B. Family Background
Father's Name: Age:
Surname First Name Middle Name Name Extension

Mother's Maiden Name: Age:

Surname First Name Middle Name

If Married, provide your spouse's full name:

Age:
Surname First Name Middle Name Name Extension

Is your family a beneficiary of 4Ps? ( ) No ( ) Yes, please provide the DSWD Household Number:
Average Monthly Household Income:

C. Educational Background
Schools Attended:

Name of School Year Graduated Average Grade Learner's Reference Number

Grade School
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.

Signature over printed name of the Applicant

II. INTERVIEW

Course Applied Second Choice Third Choice

Criteria Rubrics
Personality 3 - Very pleasing 2 - Pleasing 1 - not pleasant
English Communication Skill 3 - Very pleasing 2 - Pleasing 1 - not pleasant
Reading Skill 3 - Very pleasing 2 - Pleasing 1 - not pleasant
Average: To get the average, add earned points and divide by 3
Equivalent Rating: Refer to Table of Equivalent below

Table Equivalent
3.0 = 95 2.7 = 92 2.4 = 89 2.1 = 86 1.8 = 83 1.5 = 80 1.2 = 77
2.9 = 94 2.6 = 91 2.3 = 88 2.0 = 85 1.7 = 82 1.4 = 79 1.1 = 76
2.8 = 93 2.5 = 90 2.2 = 87 1.9 = 84 1.6 = 81 1.3 = 78 1.0 = 75

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: Equivalent Rating + Add-on Points

Signature over printed name of the Interviewer

III. EXAMINATION PERMIT

Name:
Course Applied:
Examinee No.:
Date of Interview: 2x2 ID picture

O.R. No./Date:
Date of Examination:

ARRABELLE B. TENEBRO, RGC

Head, Office of the Guidance Services
I. PERSONAL DATA

A. Personal Information
NAME:
Surname Given Name Middle Name
Date of Birth: Place of Birth: Age:
Gender: Nationality: Religion:
Civil Status: