COLLEGE

OF
ENGINEERING
Unive University of the Philippines
Melchor Hall, U.P. Campus, Diliman, Quezon City, Philippines 1101
______________________________________________________________________________________________
Tel. No. 920-8860; 928-3144; 9818500 Loc. 3104

DATA PRIVACY CONSENT FORM

For Graduating Students
In the event my graduation is approved by the University’s Board of Regents upon the
recommendation of the proper University bodies, I am allowing the following organizations
of the University of the Philippines Diliman (UPD) to carry out the specified tasks indicated
below:

Note: Please tick any, all, or none of the following options

q UPD College of Engineering and Engineering Student Council

I authorize the College (thru the Office of the College Secretary/National Graduate
School of Engineering, whichever is applicable) to share my complete name, degree
program, Latin honors information, and General Weighted Average (for those with
Latin honors only) for the preparation and publishing of materials related to the 2018
College of Engineering Recognition Rites.

q UPD Engineering Student Council

I authorize the UPD COE to share with the Engineering Student Council (ESC) my
complete name, degree program, Latin honors information, and General Weighted
Average (for those with Latin Honors only) in connection with the preparation and
publishing of materials related to the 2018 College of Engineering Recognition Rites.

q University of the Philippines Alumni Engineers (UPAE)

I authorize the UPD COE to share with the UPAE my complete name, degree program,
mobile number, email address, and permanent address for inclusion in the Alumni
Database.

I understand that the organization/s that I selected above is/are seeking my consent as the
published materials and/or databases may be accessed by members of the public.

I also affirm that my refusal to give consent to any or all of the organizations indicated above
will lead to the non-inclusion of my personal information (i.e., complete name, degree
program, Latin honors information, GWA, mobile number, email address, and permanent
address) in any published material and/or databases related to my graduation.

___________________________________ _______________________
Printed Name of Student (Last Name, First Name) Signature

Degree Program: ____________________________

Date Signed: ______________________