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-19-09364-5878
Application Number
I. PERSONAL INFORMATION (To be filled in by APPLICANT)
A. Personal Data
Name: BATISTIS ART EMMAN NACIONAL
Surname First Name Middle Name Name Extension

Sex MALE Civil Status SINGLE Nationality FILIPINO Religion CATHOLIC

Date of Birth (yyyy-mm-dd) 2000-10-09 Place of Birth TACLOBAN CITY Age 18

Permanent Address JERUSALEM ST. V AND G SUBD. PHASE 4 EXT BARANGAY 109 (V & G SUBD.)
House/Block/Lot No./Street/Subdivision/Village Barangay
TACLOBAN CITY (CAPITAL) LEYTE 60500
Town/City/Municipality Province Zip Code

Phone 09058447131 Email emmankhamatis@yahoo.com

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

B. Family Background
Father's Name BATISTIS ARTURO ESPADILLA Age 56
Surname First Name Middle Name Name Extension

Mother's Maiden Name NACIONAL EMMA CEPRINO Age 54

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 15000

C. Educational Background
Curriculum: [_] ALS [_] BEC [X] SENIOR HIGH SCHOOL TRACK: ABM
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School RIZAL CENTRAL SCHOOL 2012
High School LEYTE NATIONAL HIGHSCHOOL 2017
Senior High School LEYTE NATIONAL HIGHSCHOOL 2019
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.

ART EMMAN N. BATISTIS

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 BSARCH MAIN CAMPUS Tacloban BSA MAIN CAMPUS Tacloban BSCE

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-19-09364-5878
Name: ART EMMAN N. BATISTIS
Course Applied: BSARCH
2x2 ID Picture
Examinee No.:
Date of Interview: Wed, Apr 10, 2019 9:00 AM
Date of Examination: Thu, May 9, 2019 8:00 AM
Testing Room MAIN CAMPUS (Tacloban) - ROOM 2

Office of the Guidance Services

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