Republic of the Philippines
Eastern Visayas State University - Tanauan Campus
Tanauan, Leyte
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
2019-35029
GOLES
Name:
Date of Birth:
☐ CONTINUING
☐ SHIFTEE
☐ 4th
☑ RETURNEE
Learner
Reference
5th
☐
Number:
Year & Course:
(Last Name)
☐ TRANSFEREE
303430110156
2nd / BS Ind. Tech. E Sem. & S.Y.
LOWELL
1st Sem. / 2023-2024
CANILLAS
(First Name)
(Middle Name)
Dec 28, 1998
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
GOLES
LEO
Sex:
Civil Status:
Citizenship:
Father's
Name:
Mother's
Maiden
Name:
Sta.Fe
N/A
N/A
CATAPAL
(Last Name)
(First Name)
(Middle Name)
CANILLAS
LILIAN
TONIDO
(Last Name)
(First Name)
(Middle Name)
ZONE 3
Permanent
Address:
SAN ROQUE
(Street Address)
SANTA FE
(City/Mun.)
Mobile Number:
09551383257
(Brgy)
LEYTE
6513
(Province)
E-Mail Address:
(Zip Code)
lowellgoles13@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. / 2023-2024.
☑
I am not having my voluntary contribution for the academic period 1st Sem. / 2023-2024.
LOWELL C. GOLES
Name and Signature of Student
_____________________
Date Signed
LILIAN C. GOLES
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 LOWELL C. GOLES, 2nd Year, BS
Ind. Tech. E .
EDERLYN C. DAGAMI, CPA, JD
Registrar
_____________
Date Signed
Downloaded By: LOWELL C. GOLES - Tue, Aug 22, 2023 6:56 AM
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