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-19-01784-0877
Application Number
I. PERSONAL INFORMATION (To be filled in by APPLICANT)
A. Personal Data
Name: ORELLANO AMY ROSE VILLAMOR
Surname First Name Middle Name Name Extension

Sex FEMALE Civil Status SINGLE Nationality FILIPINO Religion CATHOLIC

Date of Birth (yyyy-mm-dd) 2001-03-10 Place of Birth ORMOC DISTRIC HOSPITAL Age 18

Permanent Address BLOCK7,LINAO LINAO

House/Block/Lot No./Street/Subdivision/Village Barangay
ORMOC CITY LEYTE 6541
Town/City/Municipality Province Zip Code

Phone 09950613854 Email ORELLANOAMIE@GMAIL.COM

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

B. Family Background
Father's Name ORELLANO MARLON BALTONADO Age 56
Surname First Name Middle Name Name Extension

Mother's Maiden Name ORELLANO MARIA THERESA VILLAMOR Age 39

Surname First Name Middle Name Name Extension

If Married,
Age 0
provide your spouse's full name
Surname First Name Middle Name Name Extension

Is your family a beneficiary of 4Ps? [_] No [X] Yes, please provide the DSWD Household Number Average Monthly Household Income 5000

C. Educational Background
Curriculum: [_] ALS [_] BEC [X] SENIOR HIGH SCHOOL TRACK: GAS
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School MONTEBELLO ELEMENTARY SCHOOL 2013 121547060059
High School LINAO NATIONAL HIGH SCHOOL 2017 121547060059
Senior High School LINAO NATIONAL HIGH SCHOOL 2019 121547060059
College

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.

AMY ROSE V. ORELLANO

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 BEED ORMOC CAMPUS BSHM

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-19-01784-0877
Name: AMY ROSE V. ORELLANO
Course Applied: BEED
2x2 ID Picture
Examinee No.:
Date of Interview: Mon, Apr 1, 2019 1:00 PM
Date of Examination: Mon, Apr 8, 2019 1:00 PM
Testing Room ORMOC CAMPUS - ROOM 1

Office of the Guidance Services

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