Republic of the Philippines

Eastern Visayas State University - Ormoc Campus

Ormoc, Leyte
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 TOR - NO LRN
Number:
Student Number: 2016-40086 Year & Course: 3rd / BSME Sem. & S.Y. 2nd Sem. / 2018-2019
Name: Doria CONRADO III Lucero
(Last Name) (First Name) (Middle Name)
Date of Birth: Apr 22, 1998 Place of Birth: Ormoc City, Leyte
Number of Academic
Sex:
☑Male ☐Female Units Enrolled:
☑ Single ☐ Married Type of Disability (if
N/A
Civil Status: ☐ Widowed ☐ Separated applicable):
Indigenous People
☐ Annuled ☐Others Affiliation (if applicable):
N/A
Citizenship: Filipino
Father's DORIA CONRADO JR CAGADAS
Name: (Last Name) (First Name) (Middle Name)

Mother's DORIA ESTRELLA LUCERO

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

WAR VETERANS AVENUE ALEGRIA

Permanent (Street Address) (Brgy)
Address: ORMOC LEYTE 6541
(City/Mun.) (Province) (Zip Code)
Mobile Number: 09062465672 E-Mail Address: doria_klydeIII@yahoo.com.ph

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.

CONRADO III Doria

Name and Signature of Student Date Signed
Conforme:

Conrado C. Doria Jr.

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: Mr. Rustico B. Badilla
I Administering Officer
ssued at:

ACKNOWLEDGMENT

This is to acknowledge receipt of the Free Higher Education and Voluntary Contribution Form of CONRADO III Doria, 3rd Year,
BSME .

Ah
Dr. Genelyn M. Calzada
Registrar Date Signed

Downloaded By: CONRADO III Doria - Sat, Jan 5, 2019 7:42 AM

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