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SPECIAL PERMIT FOR CAMPUS ACCESS (SPCA)

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IMPORTANT - PLEASE READ FIRST!
(1) This form is used oNLY for requesting permission for ACCESS OF PERSOiIS into the campus.
(2) This form willbe accepted only within office hours (Mon to Fri:8i00am to 12:00pm and 1:30pm to 5;00pm)
(3) This form must be submitted at the Secudty Oflice (J108)no leter thar two (2) vyo*ing days before the -? +*'f i3lr0 ri
requesled date ol campus access. (Salurday ls rlot counted as a wo*ing day for lhis purpose)
(4)
(5)
This form is considered an application only unless a flnaldecision is made and indicated on this fonn.
Clinics in campus are opefl only from 06:00am lo 10:00pm, Mondays lo Salurdays. frb ,]:-5*-5iCUE *FTICE

REQUEST DETAILS
Activity Type of Campus Access

B [CA.l) Pre-registration of Visitor!/

(l\,lay enter any gate)

Request
Fr tm To
Venue
E [cA-2] Extended Stayz
Date Time Date Time (10:00pm to 01:00am)

1 June 15,2017 9:00 AM June 15,2017 6;00 PM 41201 O [cA.3] ovemightz

2 (01:00am to 06:00am)
3 E [cA4] Sunday / Holidayz
4

Total# of Persons I
a; ) 2 With oubidors? (Yes I No) Yes
0
(08:00am to 06:00pm only)

[CA-51 Exemprion lrom RESTRICTED

campus accessz

Faculty ln.Charge (for slud miactiyjlips{ Requesting Party

ist of PerBons to be Covered by Special Permit

Pf
L

Name (Last, Ft n, Middle) Classification Mobile / Email Address

1 Emir Mendoza Speaker Y: emir vmen AE',IR JANT REDNDO
.T.T-I 1
.z/- aoterl oominique Echiverri Speaker Y: dominechi2403 Signature over printed name / Date
Supelising Administrator
A, (Head of Office / 0SA for student adivities)

6.

7 L*r) ,t tY U? Df l'") ,l
Please attr Lch a separale sheet if necessary (following the lormatabove) Signalure over printed name / Date

REQUESTING PARTY
/ Organization Name of Requesting Party / Position

Lasallian Scholars Society Arvir Jane R. Redondo / AVP Activties

Office Location Tol./Local No. lD No. Mobile No. EmailAddrss

N/A 11529741 0977't843699 arvir redondo @dlsu.edu.ph

APPROVAT
Approval (for Types CA-l, CA-2, CA-3) Approval
': Conditions
Endorsement (for Types CA4, CA-s) (for Types CA4, CA-s)- ..

Director, Security Vice Chancellor for Ad min istralion o No aircon

o Single entry only

tt c5r tr
1/ Prc-regislered visitors will be a valid lD. To lacilikte enw and avoid delays duo to veitication, il is advisable lo have a copy of the aryrcved
lam for prcsentation al lhe rcgatding enlry, please cal (02) 524-461 1 , local 444
u A copy of lhe awroved lom nust be readily available lor prcsentation.