EASTERN VISAYAS STATE UNIVERSITY
Tacloban City
Title of Form: EVSU Admission Application Form
Control No. EVSU-SASO-F-055
Revision No. 2
Date Feb. 24, 2020
O-23-1-07575-2150
Application ID
I. PERSONAL INFORMATION (To be filled in by APPLICANT)
A. Personal Data
Name: YBAñEZ MA. JOSEFA GIñOSO
Surname First Name Middle Name Name Extension
Sex FEMALE Civil Status SINGLE Nationality FILIPINO Religion ROMAN CATHOLIC
Date of Birth (yyyy-mm-dd) 2005-05-10 Place of Birth ORMOC Age 17
Permanent Address L. LAURENTE STREET DONGHOL
House/Block/Lot No./Street/Subdivision/Village Barangay
ORMOC CITY LEYTE 6541
Town/City/Municipality Province Zip Code
Phone 09385022245 Email ybanezmajosefa10@gmail.com
Do you have any disability? [X] NO [_] Yes, please specify None Height 150 cm. Weight 53 kg.
B. Family Background
Father's Name YBAñEZ ARNELO LATONIO Age 51
Surname First Name Middle Name Name Extension
Mother's Maiden Name YBAñEZ LINDY GIñOSO Age 42
Surname First Name Middle Name Name Extension
If Married,
provide your spouse's full name Age
Surname First Name Middle Name Name Extension
Is your family a beneficiary of 4Ps? [_] No [X] Yes, please provide the DSWD Household Number 0800005835771 Average Monthly Household
Income < 9,100
C. Educational Background
Curriculum: [_] ALS [_] Transferee [X] SENIOR HIGH SCHOOL TRACK: HUMSS
Schools Attended:
Name of School Year Graduated Average Grade Learner's Reference Number
Grade School DONGHOL ELEMENTARY SCHOOL 2017 194501100560
High School NEW ORMOC CITY NATIONAL HIGH SCHOOL 2021 194501100560
Senior High School ORMOC CITY SENIOR HIGH SCHOOL 2023 194501100560
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.
MA. JOSEFA G. YBAñEZ
Signature over printed name of the Applicant
II. EXAMINATION PERMIT (To be filled in by OGS)
Application ID: O-23-1-07575-2150
Name: MA. JOSEFA G. YBAñEZ
Course Applied: BTVTED FSM
Date and Time of Examination: Thu, May 18, 2023 1:00 PM
Campus / Testing Room ORMOC CAMPUS
Office of the Guidance Services
Downloaded By: MA. JOSEFA G. YBAñEZ , Sat, Apr 15, 2023 2:09 PM
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