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

00 2019

Republic of the Philippines

EASTERN VISAYAS STATE UNIVERSITY
Tacloban City
STUDENT AFFAIRS AND SERVICES OFFICE
Office of Guidance Services

EVSU ADMISSION APPLICATION FORM 2x2 ID Picture

O-19-09000-2382
Application Number
I. PERSONAL INFORMATION (To be filled in by APPLICANT)
A. Personal Data
Name: CAñETE EDWIN ALTERADO
Surname First Name Middle Name Name Extension

Sex MALE Civil Status SINGLE Nationality FILIPINO Religion ROMAN CATHOLIC

Date of Birth (yyyy-mm-dd) 1991-12-22 Place of Birth SILAD VILLAB,LEYTE Age 27

Permanent Address SITIO BAY-ANG SALVACION

House/Block/Lot No./Street/Subdivision/Village Barangay
ORMOC CITY LEYTE 06541
Town/City/Municipality Province Zip Code

Phone 09071711160 Email akpedwin1973@gmail.com

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

B. Family Background
Father's Name CAñETE ERLINDO SARCO Age 59
Surname First Name Middle Name Name Extension

Mother's Maiden Name ALTERADO BONIFACIA MONARES Age 62

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? [X] No [_] Yes, please provide the DSWD Household Number Average Monthly Household Income 10000

C. Educational Background
Curriculum: [_] ALS [X] BEC [_] SENIOR HIGH SCHOOL TRACK:
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School BRGY.SANTO NIñO ELEMENTARY SCHOOL 2005
High School NEW ORMOC CITY NATIONAL HIGH SCHOOL 2009
Senior High School
College EASTERNN VISAYAS STATE UNIVERSITY

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.

EDWIN A. CAñETE
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
ORMOC CAMPUS BSED SCI ORMOC CAMPUS BSED MATH

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.:
O-19-09000-2382
Name: EDWIN A. CAñETE
Course Applied: BSED SCI
2x2 ID Picture
Examinee No.:
Date of Interview: Fri, Mar 29, 2019 9:00 AM
Date of Examination: Sat, Mar 30, 2019 8:00 AM
Testing Room ORMOC CAMPUS - ROOM 1

Office of the Guidance Services

Downloaded By: EDWIN A. CAñETE , Thu, Mar 28, 2019 11:12 AM