Republic of the Philippines

Burauen Community College

Burauen, Leyte
FREE HIGHER EDUCATION AND VOLUNTARY CONTRIBUTION FORM
PERSONAL INFORMATION
⃝ NEW ENROLLEE ⃝ CONTINUING ⃝ SHIFTEE ⃝ RETURN ⃝ TRANSFEREE
Learner
Year Level: ⃝ 1st ⃝ 2nd ⃝ 3rd ⃝ 4th ⃝ 5th Reference Number:

Student Number:2022- Year & Course: BSCRIMINOLOGY Sem.& S.Y. 1ST

Name:
(Last Name) (First Name) (Middle Name)
Date of Birth: Place of Birth:

Number of Academic 26
Sex: ⃝ Male ⃝ Female
Units Enrolled:
⃝ Single ⃝ Married Type of Disability
N/A
(if applicable):
Civil Status: ⃝ Widowed ⃝ Separated Indigenous People
Affiliation (if applicable): N/A
⃝ Annulled ⃝ Others
Citizenship:
Father's
Name: (Last Name) (First Name) (Middle Name)
Mother's
Maiden Name: (Last Name) (First Name) (Middle Name)
Permanent
Address: (Street Address) (Brgy.)

(City/Mun) (Province) (Zipcode)

Mobile Number: E-Mail Address:
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.
I CERTIFY FURTHER that I am cognizant of and aware of the provisions in RA 10931 (Universal Access to Quality
Tertiary Education Act) and all the benefits and responsibilities under the Act. I voluntarily avail of the Free Higher
Education benefits and privileges and abide by the return service obligation inherent thereto.
⃝ I am voluntarily contributing an amount of____________(Php____) for the academic period _________.
⃝ I am not having my voluntary contribution for the academic period 1ST SEM 2022-2023.

Conforme: Name and Signature of Student Date Signed

Name and Signature of Parent/Guardian Date Signed

free Higher Education. ATTY. ABSALON G. APOSTOL

ID No: 2022- CPA
Issued by: SHARON D. BARTOLO Administering Officer
Issued at: BURAUEN, LEYTE
ACKNOWLEDGMENT
This is to acknowledge receipt of the Free Higher Education and Voluntary Contribution Form of

JOSEFINA S. APOSTOL, MBBM __________________

Registrar Date Signed