Republic of the Philippines
Eastern Visayas State University
Tacloban City
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
Year Level:
☐ 1st
Student Number:
☑ 2nd
☐ 3rd
2020-02720
MARTINEZ
Name:
Date of Birth:
☑ CONTINUING
☐ SHIFTEE
☐ 4th
☐ RETURNEE
Learner
Reference
5th
☐
Number:
Year & Course:
(Last Name)
☐ TRANSFEREE
125106070047
2nd / BSARCH
JETHRO
Sem. & S.Y.
(First Name)
(Middle Name)
Jul 15, 2002
Place of Birth:
Number of Academic
☑ Male ☐ Female
Units Enrolled:
Type of Disability (if
☑ Single ☐ Married
applicable):
Widowed
Separated
☐
☐
Annuled
Others
Indigenous People
☐
☐
Affiliation (if applicable):
__________
FILIPINO
MARTINEZ
ROLDAN
Sex:
Civil Status:
Citizenship:
Father's
Name:
Mother's
Maiden
Name:
Picanan, Kumalarang, Zamboanga del Sur
N/A
N/A
DUMABOC
(Last Name)
(First Name)
(Middle Name)
ESPLANA
JACKELYN
ENDAC
(Last Name)
(First Name)
(Middle Name)
ZONE 10
Permanent
Address:
1st Sem. / 2021-2022
ESPLANA
TELEGRAFO
(Street Address)
TOLOSA
(City/Mun.)
Mobile Number:
09106324353
(Brgy)
LEYTE
6503
(Province)
E-Mail Address:
(Zip Code)
jethromartinez2@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 1st Sem. / 2021-2022.
☑
I am not having my voluntary contribution for the academic period 1st Sem. / 2021-2022.
JETHRO MARTINEZ
Name and Signature of Student
_____________________
Date Signed
Jackelyn Esplana Martinez
Name and Signature of Parent/Guardian
_____________________
Date Signed
Conforme:
Subscribed and sworn to before me this _______ day of _____________ for purposes of availing the Free Higher Education.
ID No.: _________
Issued by: _______
Issued at: ________
____________________________
Administering Officer
ACKNOWLEDGMENT
This is to acknowledge receipt of the Free Higher Education and Voluntary Contribution Form of JETHRO MARTINEZ, 2nd Year,
BSARCH .
JUDITH P. CAMPO, MPRM
Registrar
_____________
Date Signed
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