MEMBERSHIP FORM

NOTE: Kindly fill out all the information required completely and legibly. Incomplete forms will not be processed.

TYPE OF □ NEW □ RENEWAL IECEP MEMBERSHIP ID —

(LEAVE BLANK IF NEW MEMBER)
MEMBERSHIP
LAST NAME

E S T R E L L A
GIVEN NAME

F R E N Z J O S H

MIDDLE NAME

A M O R E S
ADDRESS

339 MAGSAYSAY STREET, BAYUGO, JALA-JALA, RIZAL

LANDLINE NO. N/A MOBILE NO. 09691704870

EMAIL ADDRESS GENDER DATE OF BIRTH (DD-MM-YYYY)
frenzjoshestrella04@gmail.com □ FEMALE □ MALE 0 4 — 1 0 — 2 0 0 4
NAME OF SCHOOL

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES – STA. MESA

NAME OF LOCAL ORGANIZATION

ELECTRONICS ENGINEERING STUDENTS' SOCIETY

YEAR AND SECTION POSITION ADVISER/S

2-1 MEMBER DR. MARIANITO P. GALLEGO JR.

APPLICANT’S CONFORME RECEIVED BY
In compliance with the Data Privacy Act (DPA) of 2012, and its Implementing Rules and
Regulations (IRR) effective since September 9, 2016, IECEP-MSC shall be granted
authority to collect, record, organize, update, use, consolidate, and delete user data
under the premise of complete confidentiality.

IECEP-MSC shall be bound to use personal information for member authentication,

attendance tracking, benefits verification, and other essential tasks within the
organization's scope.

FRENZ JOSH A. ESTRELLA BILLY_ M. ALIPALA_ _

APPLICANT’S SIGNATURE OVER PRINTED NAME BOD’S SIGNATURE OVER PRINTED NAME

FULL NAME (LAST NAME, GIVEN NAME, MIDDLE NAME) SCHOOL

ESTRELLA, FRENZ JOSH, AMORES POLYTECHNIC UNIVERSITY OF THE PHILIPPINES –

STA. MESA
CONTACT NO. (LANDLINE, MOBILE) IECEP MEMBERSHIP ID

09691704870 —
ADDRESS

339 MAGSAYSAY STREET, BAYUGO, JALA-JALA, RIZAL