SULTAN KUDARAT STATE UNIVERSITY

ACCESS, EJC Montilla, Tacurong City

TACURONG Campus

PERSONAL INFORMATION SHEET

Last Name: DUMALAG First name: DIVINA Middle Name: ACAPULCO Ext name N/A
LRN number:_______________Email address: bingvinedumalag@yahoo.com Mobile number :09171466412
Birth date:OCTOBER 24, 1977 Birth place: CEBUANO, TUPI, SOUTH COTABATO
Gender FEMALE Blood type: AB Nationality:FILIPINO Tribal Affiliation:CEBUANO Civil Status:MARRIED
Address :
Street:PAG-ASA 1 Barangay: CEBUANO Municipality:TUPI Province: SOUTH COTABATO
Legal guardian: ERNESTO R. DUMALAG, JR. Contact number of guardian 09770910784
Address of Guardian:PAG-ASA 1, CEBUANO, TUPI, SOUTH COTABATO
4Ps household ID No.:_____________ Listahan ID no.:__________ Household income:_______ total no. of Dependents:___
Tertiary Education
Name of school:MINDANAO STATE UNIVERSITY- GSC
Address of School:BARANGAY FATIMA, GENERAL SANTOS CITY
School last attended (for transferees only)
Name of school:_____________________________________________________________________________________
Address of school: ___________________________________________________________________________________
__________________________________________________________________________________________________

SULTAN KUDARAT STATE UNIVERSITY

Office of the Registrar
TACURONG Campus

DATA PRIVACY CONSENT FORM

I, DIVINA ACAPULCO-DUMALAG completely aware that SKSU values the confidentiality of personal information data to
comply with the Data Privacy Act of 2012 in order to protect my right to Data Privacy on my personal information which
includes but not limited to my name, address, names of my parents or guardians, date and place of birth, grades,
attendance, and other information essential for basic administration of instruction.
I know that my personal information cannot be disclosed without my consent. I understand that the information that
was collected and processed related to my enrollment will be used by SKSU to monitor its legitimate interests as an
educational institution. Similarly, I am fully aware that SKSU may share such information to affiliated organizations as
part of its obligations, or with government agencies pursuant to law or legal processes. In this respect, I hereby allow
SKSU to collect, process, use and share my personal data in the pursuit of its authentic interests as a learning institution.
In addition, I am giving my consent in favor of my parents/guardian or representative to access, scrutinize and or check
my academic and scholastic records, school accounts in the University, and all matters that relate to my status as a
student of the University.
Lastly, should I commit any misbehavior or should there be a complaint filed against me by reason of violation of the
provisions of the Student Manual or any laws or ordinances, I hereby authorize and give my full consent in favor of the
University to inform my parents, guardian, or representative.

DIVINA ACAPULCO - DUMALAG

Printed Name and signature of student

____________________
Date