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

O-19-11817-2858
Application Number
I. PERSONAL INFORMATION (To be filled in by APPLICANT)
A. Personal Data
Name: MORA MARY JEAN LUCERO
Surname First Name Middle Name Name Extension

Sex FEMALE Civil Status SINGLE Nationality FILIPINO Religion ROMAN CATHOLIC

Date of Birth (yyyy-mm-dd) 1999-09-08 Place of Birth ORMOC CITY Age 19

Permanent Address TINAG AN 1 IPIL ORMOC CITY IPIL

House/Block/Lot No./Street/Subdivision/Village Barangay
ORMOC CITY LEYTE 6541
Town/City/Municipality Province Zip Code

Phone 09076752166 Email pretete148@gmail.com

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

B. Family Background
Father's Name MORE GENARO DELIMA JR Age 54
Surname First Name Middle Name Name Extension

Mother's Maiden Name MORE CONCHITA LUCERO Age 56

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? [_] No [X] Yes, please provide the DSWD Household Number Average Monthly Household Income 7000

C. Educational Background
Curriculum: [_] ALS [_] BEC [X] SENIOR HIGH SCHOOL TRACK: GAS
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School IPIL CENTRAL SCHOOL 2013
High School IPIL NATIONAL HIGH SCHOOL 2017 124155060115
Senior High School IPIL NATIONAL HIGH SCHOOL 2019 124155060115
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.

MARY JEAN L. MORA

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
ORMOC CAMPUS BSED SCI ORMOC CAMPUS BPED ORMOC CAMPUS BTVTED FSM

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.:
O-19-11817-2858
Name: MARY JEAN L. MORA
Course Applied: BSED SCI
2x2 ID Picture
Examinee No.:
Date of Interview: Fri, May 10, 2019 1:00 PM
Date of Examination: Sat, May 11, 2019 8:00 AM
Testing Room ORMOC CAMPUS - ROOM 1

Office of the Guidance Services

Downloaded By: MARY JEAN L. MORA , Fri, Apr 12, 2019 12:07 PM