Republic of the Philippines

Eastern Visayas State University

Tacloban City
2x2 ID Picture
FREE HIGHER EDUCATION AND VOLUNTARY CONTRIBUTION FORM

Instruction: Fill in all required information. Do not leave an item blank. If item is not applicable indicate "N/A".

PERSONAL INFORMATION
☐ NEW ENROLLEE ☑ CONTINUING ☐ SHIFTEE ☐ RETURNEE ☐ TRANSFEREE
Learner
Year Level: ☐ 1st ☐ 2nd ☐ 3rd ☐ 4th ☑ 5th Reference NO LRN
Number:
Student Number: 2010-00091 Year & Course: 5th / BSCE Sem. & S.Y. 2nd Sem. / 2018-2019
Name: GONZAGA CHRISTIAN JAY SIA
(Last Name) (First Name) (Middle Name)
Date of Birth: Dec 24, 1996 Place of Birth: TAC. CITY
Number of Academic
Sex: ☑ Male ☐ Female Units Enrolled:
☑ Single ☐ Married Type of Disability (if
N/A
Civil Status: ☐ Widowed ☐ Separated applicable):
☐ Annuled ☐ Others Indigenous People
N/A
__________ Affiliation (if applicable):
Citizenship: FILIPINO
Father's GONZAGA SALVADOR GABALES
Name: (Last Name) (First Name) (Middle Name)

Mother's SIA MARILOU UY

Maiden
Name: (Last Name) (First Name) (Middle Name)

385 BETHLEHEM ST. PHASE 4 EXT. BRGY. 109-A

Permanent (Street Address) (Brgy)
Address: TACLOBAN CITY LEYTE 6500
(City/Mun.) (Province) (Zip Code)
Mobile Number: 09554858615 E-Mail Address: christianjaygonzaga@gmail.com

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.

I CERTIFY FURTHER that I am cognizant of and aware of the provisions in RA 10931 (Universal Access to Quality Tertiary
Education Act) and all the benefits and responsibilities under the Act. I voluntarily avail of the Free Higher Education benefits and
privileges and abide with the return service obligation inherent thereto.

☐ I am voluntarily contributing an amount of __________________ (PhP _____) for the academic period 2nd Sem. / 2018-2019.

☑ I am not having my voluntary contribution for the academic period 2nd Sem. / 2018-2019.

CHRISTIAN JAY GONZAGA _____________________

Name and Signature of Student Date Signed
Conforme:

MARILOU S. GONZAGA _____________________

Name and Signature of Parent/Guardian Date Signed

Subscribed and sworn to before me this _______ day of _____________ for purposes of availing the Free Higher Education.

ID No.: _________
____________________________
Issued by: _______
Administering Officer
Issued at: ________

ACKNOWLEDGMENT

This is to acknowledge receipt of the Free Higher Education and Voluntary Contribution Form of CHRISTIAN JAY GONZAGA, 5th
Year, BSCE .

____________________________ _____________
Registrar Date Signed

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