EASTERN VISAYAS STATE UNIVERSITY

Tacloban City
Control No. EVSU-SASO-F-055
Revision No. 1
Title of Form: EVSU Admission Form Application Form
Date Feb. 24, 2020

B-22-1-11179-0341
Application Number

I. PERSONAL INFORMATION (To be filled in by APPLICANT)

A. Personal Data
Name: AGRAVA CRISTINE MONTE
Surname First Name Middle Name Name Extension

Sex FEMALE Civil Status SINGLE Nationality FILIPINO Religion ROMAN CATHOLIC

Date of Birth (yyyy-mm-dd) 2002-08-23 Place of Birth BURAUEN LEYTE Age 19

Permanent Address N/A HUGPA EAST

House/Block/Lot No./Street/Subdivision/Village Barangay
BURAUEN LEYTE N/A
Town/City/Municipality Province Zip Code

Phone +1639700885054 Email cristineagrava90@gmail.com

Do you have any disability? [X] NO [_] Yes, please specify NONE

B. Family Background
Father's Name AGARAVA ROBERTO JUNTO Age 47
Surname First Name Middle Name Name Extension

Mother's Maiden Name MONTE CONCHITA CAINDOY Age 46

Surname First Name Middle Name Name Extension

If Married,
N/A N/A N/A N/A 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 5000

C. Educational Background
Curriculum: [_] ALS [_] BEC [X] SENIOR HIGH SCHOOL TRACK: HUMSS
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School MALABCA ELEMENTARY SCHOOL 2015 121165090002
BURAUEN COMPREHENSIVE NATIONAL HIGH
High School 2020 121165090002
SCHOOL
BURAUEN COMPREHENSIVE NATIONAL HIGH
Senior High School 2022 121165090002
SCHOOL
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.

CRISTINE M. AGRAVA
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
BURAUEN CAMPUS BEED BURAUEN CAMPUS BEED BURAUEN CAMPUS BEED

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.:
B-22-1-11179-0341
Name: CRISTINE M. AGRAVA

Course Applied: BEED

Date of Interview:

Date of Examination:

Testing Room

Office of the Guidance Services

Downloaded By: CRISTINE M. AGRAVA , Thu, Apr 7, 2022 10:16 PM