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REVOLU T IONIZ INGED UCAT ION

(Dean’s copy)
STUDENT CONSULTATION
Name of Student: ______________________________________ Date: ____________________
Course Adviser: ______________________________________ Year & Section: ____________________
Class Schedule: ______________________________________ Contact No.: ____________________

Nature of Problem/Concern: _______________________________________________________________________


Details:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Provision/s Given:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

I, Mr./Ms. ________________________________ have consulted with the subject adviser regarding the
problem/concern and have agreed upon (as stated above) the solution. I hereby affix my signature.

Parent’s Address:________________________________ Contact No.: ______________________________

__________________________ __________________________
Student/Parent’s Signature Course Adviser’s Signature

Course adviser’s verification/remarks on the provision/s given to the student:


_______________________________________________________________________________________________
_______________________________________________________________________________________________

F-VPA-009 (01-06-14)

REVOLU T IONIZ INGED UCAT ION

(Student’s copy)
STUDENT CONSULTATION
Name of Student: ______________________________________ Date: ____________________
Course Adviser: ______________________________________ Year & Section: ____________________
Class Schedule: ______________________________________ Contact No.: ____________________

Nature of Problem/Concern: _______________________________________________________________________


Details:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Provision/s Given:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

I, Mr./Ms. ________________________________ have consulted with the subject adviser regarding the
problem/concern and have agreed upon (as stated above) the solution. I hereby affix my signature.

Parent’s Address:________________________________ Contact No.: ______________________________

__________________________ __________________________
Student/Parent’s Signature Course Adviser’s Signature

Course adviser’s verification/remarks on the provision/s given to the student:


_______________________________________________________________________________________________
_______________________________________________________________________________________________

F-VPA-009 (01-06-14)

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