EASTERN VISAYAS STATE UNIVERSITY

Tacloban City
Control No. EVSU-SASO-F-055
Revision No. 2
Title of Form: EVSU Admission Application Form
Date Feb. 24, 2020

D-24-1-11529-0113
Application ID

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

A. Personal Data
Name: CURITANA JANDIL-AM ABCDEF SAñO
Surname First Name Middle Name Name Extension

Sex MALE Civil Status SINGLE Nationality FILIPINO Religion ROMAN CATHOLIC

Date of Birth (yyyy-mm-dd) 2006-01-20 Place of Birth DULAG, LEYTE Age 18

Permanent Address ZONE 3 MAGSAYSAY

House/Block/Lot No./Street/Subdivision/Village Barangay
DULAG LEYTE 6505
Town/City/Municipality Province Zip Code

Phone 09770659564 Email joyrossilsano18@gmail.com

Do you have any disability? [X] NO [_] Yes, please specify None Height 162 cm. Weight 59 kg.

B. Family Background
Father's Name CURITANA JOEY BAROñA Age 41
Surname First Name Middle Name Name Extension

Mother's Maiden Name SAñO JENNELYN ARTUGUE Age 39

Surname First Name Middle Name Name Extension

If Married,
Age
provide your spouse's full name
Surname First Name Middle Name Name Extension

Average Monthly Household

Is your family a beneficiary of 4Ps? [_] No [X] Yes, please provide the DSWD Household Number 083718038-294700001 < 9,100
Income

C. Educational Background
Curriculum: [_] ALS [_] Transferee [X] SENIOR HIGH SCHOOL TRACK: TVL
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School SAN AGUSTIN ELEMENTARY SCHOOL 2018
High School DULAG NATIONAL HIGH SCHOOL 2022 121331110010
Senior High School DULAG NATIONAL HIGH SCHOOL 121331110010
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.

JANDIL-AM ABCDEF S. CURITANA

Signature over printed name of the Applicant

II. EXAMINATION PERMIT (To be filled in by OGS)

Application ID:
D-24-1-11529-0113
Name: JANDIL-AM ABCDEF S. CURITANA

Course Applied: BSOA

Date and Time of Examination: Mon, Feb 26, 2024 8:00 AM

Campus / Testing Room DULAG CAMPUS

Office of the Guidance Services

Downloaded By: JANDIL-AM ABCDEF S. CURITANA , Sat, Feb 24, 2024 12:01 PM