Republic of the Philippines

Eastern Visayas State University

Tacloban City

FREE HIGHER EDUCATION AND VOLUNTARY CONTRIBUTION FORM

Instruction: Fill in all required information. Do not leave an item blank. If item is not applicable indicate "N/A".

PERSONAL INFORMATION
☐ NEW ENROLLEE ☑ CONTINUING ☐ SHIFTEE ☐ RETURNEE ☐ TRANSFEREE
Learner
Year Level: ☑ 1st ☐ 2nd ☐ 3rd ☐ 4th ☐ 5th Reference 123307090013
Number:
Student Number: 2022-09013 Year & Course: 1st / BCAEd Sem. & S.Y. 2nd Sem. / 2022-2023
Name: BACLAYO IVORY ROSE FUNCION
(Last Name) (First Name) (Middle Name)
Date of Birth: Feb 21, 2004 Place of Birth: Brgy. Baybay Basey, Samar
Number of Academic
Sex: ☐ Male ☑ Female Units Enrolled:
☑ Single ☐ Married Type of Disability (if
N/A
Civil Status: ☐ Widowed ☐ Separated applicable):
☐ Annuled ☐ Others Indigenous People
N/A
__________ Affiliation (if applicable):
Citizenship: FILIPINO
Father's BACLAYO BRECCIO CHAVEZ
Name: (Last Name) (First Name) (Middle Name)

Mother's FUNCION ROSITA AGOJERO

Maiden
Name: (Last Name) (First Name) (Middle Name)

CONG. VALERIANO YANCHA ST. BAYBAY (POB.)

Permanent (Street Address) (Brgy)
Address: BASEY SAMAR (WESTERN SAMAR) 6720
(City/Mun.) (Province) (Zip Code)
Mobile Number: 09182335927 E-Mail Address: baclayoivoryrose@gmail.com

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.

I CERTIFY FURTHER that I am cognizant of and aware of the provisions in RA 10931 (Universal Access to Quality Tertiary
Education Act) and all the benefits and responsibilities under the Act. I voluntarily avail of the Free Higher Education benefits and
privileges and abide with the return service obligation inherent thereto.

☐ I am voluntarily contributing an amount of __________________ (PhP _____) for the academic period 2nd Sem. / 2022-2023.

☑ I am not having my voluntary contribution for the academic period 2nd Sem. / 2022-2023.

IVORY ROSE BACLAYO _____________________

Name and Signature of Student Date Signed
Conforme:

Rosita F. Baclayo _____________________

Name and Signature of Parent/Guardian Date Signed

Subscribed and sworn to before me this _______ day of _____________ for purposes of availing the Free Higher Education.

ID No.: _________
____________________________
Issued by: _______
Administering Officer
Issued at: ________

ACKNOWLEDGMENT

This is to acknowledge receipt of the Free Higher Education and Voluntary Contribution Form of IVORY ROSE BACLAYO, 1st Year,
BCAEd .

JUDITH P. CAMPO, MPRM _____________

Registrar Date Signed

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