EVSU-1-ACA-16.037-0002 Revision No.

00 2019

Republic of the Philippines

EASTERN VISAYAS STATE UNIVERSITY
Tacloban City
STUDENT AFFAIRS AND SERVICES OFFICE
Office of Guidance Services

EVSU ADMISSION APPLICATION FORM 2x2 ID Picture

M-19-10520-6620
Application Number
I. PERSONAL INFORMATION (To be filled in by APPLICANT)
A. Personal Data
Name: CLARIDAD MARCEL JOSEPH CHAN
Surname First Name Middle Name Name Extension

Sex MALE Civil Status SINGLE Nationality FILIPINO Religion CATHOLIC

Date of Birth (yyyy-mm-dd) 1999-12-21 Place of Birth TACLOBAN Age 19

Permanent Address 128 FATIMA STREET B1 L5 PH.4 EXT V AND G SUBDIVISION TACLOBAN CITY BARANGAY 109 (V & G SUBD.)
House/Block/Lot No./Street/Subdivision/Village Barangay
TACLOBAN CITY (CAPITAL) LEYTE 6500
Town/City/Municipality Province Zip Code

Phone 09661350439 Email mjclaridad75@yahoo.com

Do you have any disability? [X] NO [_] Yes, please specify

B. Family Background
Father's Name CLARIDAD EDWIN DEPAZ Age 55
Surname First Name Middle Name Name Extension

Mother's Maiden Name CLARIDAD JUDITH CHAN Age 50

Surname First Name Middle Name Name Extension

If Married,
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 4000

C. Educational Background
Curriculum: [_] ALS [_] BEC [X] SENIOR HIGH SCHOOL TRACK: STEM
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School CAINTA CATHOLIC COLLEGE 2013
High School HOLLY INFANT COLLEGE 2017 404801150272
Senior High School HOLLY INFANT COLLEGE 2019 404801150272
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.

MARCEL JOSEPH C. CLARIDAD

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
MAIN CAMPUS Tacloban BSCE MAIN CAMPUS Tacloban BSIENG MAIN CAMPUS Tacloban BSARCH

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.:
M-19-10520-6620
Name: MARCEL JOSEPH C. CLARIDAD
Course Applied: BSCE
2x2 ID Picture
Examinee No.:
Date of Interview: Wed, Apr 10, 2019 9:00 AM
Date of Examination: Tue, May 14, 2019 1:00 PM
Testing Room MAIN CAMPUS (Tacloban) - ROOM 2

Office of the Guidance Services

Downloaded By: MARCEL JOSEPH C. CLARIDAD , Sat, Apr 6, 2019 10:41 PM