AGILA 2019

THE OFFICIAL YEARBOOK OF USeP

APPLICATION FORM

Name: _______________________________ _____________________ ___________

Family Name Given Name Middle Name

Date of Birth: _______________ Contact Number: _________________ Email Ad: _________________

Course: ______________________________________________________________________________
Graduated AY 2018 – 2019: Please Check (✓)
( ) 1st Semester 2018-19 ( ) Off-semester 2019
( ) 2nd Semester 2018-19

Permanent Address: ___________________________________________________________________

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(House No., Lot, Blk, Phase, Prk, Street, Subdivision/Village, Brgy., City/Town, Province)
Father’s Name: _____________________________________________________
Mother’s Name: ____________________________________________________
Spouse’s Name: ____________________________________________________

Organizational Affiliation/s: [maximum of three (3)] (START FROM THE MOST RECENT)

*Position, Organization (write in full), Inclusive Years (e.g. Governor, CGB Local Council, 2018-2019)

Awards & Other Citations: [maximum of three (3)] (START FROM THE MOST RECENT)

Competition: Rank, Competition Name, Year (e.g. 1st Place, Motions in Motion, 2018)
Academic Excellence: *Award, Semester, Year (e.g. Dean’s Lister, 1st Semester, 2017-2018)

Thesis Title (For Graduate School Only):

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_____________________________________________________________________________________

Terms and Conditions:

 Any interested student-subscriber shall fill out an application form and once submitted is subject to
the policy and the rules of the yearbook.
 There shall be one (1) collection period for the payment of the yearbook. Payment shall be made to
the college moderator. Payment needs to be prompt. Failure to do so may mean cancellation to the
subscription.
 Subscription fee is P 1,900.00 (non-refundable) payable on or before June 28, 2019
 In case the subscriber will not be able to graduate on the same year the subscription was made,
his/her subscription shall be cancelled.
 School clearance of the subscriber shall not be signed/released until full payment is made.
 No retraction shall be allowed after the signing of contract between the printing press and the
advisory board.

As confirmed graduate, I voluntarily subscribe to the University Yearbook AY 2018-2019.

Conforme:

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Student Signature above Printed Name

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Parent/Guardian Signature above Printed Name

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Date Submitted