Reference No.: BatStateU-FO-OGC-11 Effectivity Date: May 18, 2022 Revision No.

: 04

EXIT INTERVIEW FORM

Please [ ] Pablo Borbon Campus [ ] Alangilan Campus [ ] Nasugbu Campus

Check: [ ] Malvar Campus [ ] Lipa Campus [ ] Lemery Campus [ ] Mabini Campus
[ ] Rosario Campus [ ] Balayan Campus [ ] San Juan Campus [ ] Lobo Campus
[ ] Shifter [ ] Transferee Last Attendance (Semester & A.Y): 1st & 2021 Date Filed: August 08, 2023
Last Name: Adion First Name: Jane M.I.: B. SR Code: 21-53417
Department: CONAHS Program: BSN Year Level: 1ST
Reason for Shifting/Transferring:
I'm pursuing the course that I really love, which Bachelor of Science in Medical Laboratory Science

Pursuant to Republic Act No. 10173, also known as the Data Privacy Act of 2012, the Batangas State
University, the National Engineering University, recognizes its commitment to protect and respect the privacy of its
customers and/or stakeholders and ensure that all information collected from them are all processed in accordance with
the principles of transparency, legitimate purpose and proportionality mandated under the Data Privacy Act of 2012.
Noted by: Interviewed by:

___________________ ___________________ _____________________ __________________

Parent/Guardian Adviser/ Dean/ Guidance Counselor/
Department/ Program Head, Academic Affairs Facilitator
Chairperson
Date: Date: Date: Date:
Remarks: Remarks: Remarks:
(OGC’s copy)

Reference No.: BatStateU-FO-OGC-11 Effectivity Date: May 18, 2022 Revision No.: 04

EXIT INTERVIEW FORM

Please [ ] Pablo Borbon Campus [ ] Alangilan Campus [ ] Nasugbu Campus

Check: [ ] Malvar Campus [ ] Lipa Campus [ ] Lemery Campus [ ] Mabini Campus
[ ] Rosario Campus [ ] Balayan Campus [ ] San Juan Campus [ ] Lobo Campus
[ ] Shifter [ ] Transferee Last Attendance (Semester & A.Y): 1st & 2021 Date Filed: August 08, 2023
Last Name: Adion First Name: Jane M.I.: B. SR Code: 21-53417
Department: CONAHS Program: BSN Year Level: 1ST
Reason for Shifting/Transferring:
I'm pursuing the course that I really love, which Bachelor of Science in Medical Laboratory Science

Pursuant to Republic Act No. 10173, also known as the Data Privacy Act of 2012, the Batangas State
University, the National Engineering University, recognizes its commitment to protect and respect the privacy of its
customers and/or stakeholders and ensure that all information collected from them are all processed in accordance with
the principles of transparency, legitimate purpose and proportionality mandated under the Data Privacy Act of 2012.
Noted by: Interviewed by:

___________________ ___________________ _____________________ __________________

Parent/Guardian Adviser/ Dean/ Guidance Counselor/
Department/ Program Head, Academic Affairs Facilitator
Chairperson
Date: August 6, 2023 Date: Date: Date:
Remarks: Remarks: Remarks:
(Student’s copy)