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

M-19-10201-6423
Application Number
I. PERSONAL INFORMATION (To be filled in by APPLICANT)
A. Personal Data
Name: MIRABEL CHRISTIAN ANDREI OGA-OGA
Surname First Name Middle Name Name Extension

Sex MALE Civil Status SINGLE Nationality FILIPINO Religion ROMAN CATHOLIC

Date of Birth (yyyy-mm-dd) 2000-12-25 Place of Birth PASIG CITY Age 18

Permanent Address PUROK 06 BARANGAY 91 (ABUCAY)

House/Block/Lot No./Street/Subdivision/Village Barangay
TACLOBAN CITY (CAPITAL) LEYTE 6500
Town/City/Municipality Province Zip Code

Phone 09453378991 Email jonavel1726@gmail.com

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

B. Family Background
Father's Name MIRABEL ALVIN BUENAFLOR Age 41
Surname First Name Middle Name Name Extension

Mother's Maiden Name MIRABEL JONAVEL OGA-OGA Age 239

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? [X] No [_] Yes, please provide the DSWD Household Number Average Monthly Household Income 20000

C. Educational Background
Curriculum: [_] ALS [_] BEC [X] SENIOR HIGH SCHOOL TRACK: TVL
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
JUDGE ANTONIO R. MONTILLA SR.
Grade School 2013
ELEMENTARY SCHOOL
High School HOLY INFANT COLLEGE 2017
Senior High School AMA COMPUTER LEARNING CENTER 2019
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.

CHRISTIAN ANDREI O. MIRABEL

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
MAIN CAMPUS Tacloban BSCE

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.:
M-19-10201-6423
Name: CHRISTIAN ANDREI O. MIRABEL
Course Applied: BSCE
2x2 ID Picture
Examinee No.:
Date of Interview: Fri, May 10, 2019 9:00 AM
Date of Examination: Tue, May 14, 2019 1:00 PM
Testing Room MAIN CAMPUS (Tacloban) - ROOM 2

Office of the Guidance Services

Downloaded By: CHRISTIAN ANDREI O. MIRABEL , Thu, Apr 4, 2019 8:28 PM