Republic of the Philippines

ABUYOG COMMUNITY COLLEGE

Abuyog, 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
Year Level: ☐ 1st ☐ 2nd ☐ 3rd ☐ 4th ☐ 5th LRN:
Student Number: Year & Course: Sem. & School Year 1st Sem A.Y. 2020-2021

Name:
(Last Name) (First Name) (Middle Name)
Date of Birth: Permanent Mailing
Place of Birth: Address:

Sex: ☐ Male ☐ Female Zip Code:

☐ Single ☐ Married Number of Academic

☐ Widowed ☐ Separated Units Enrolled:
Civil Status: Annuled
☐ ☐ Others Type of Disability (if
applicable):
Citizenship: Indigenous People
Affiliation (if applicable):
Mobile Number:
E-Mail Address: Facebook Account:

I HEREBY CERTIFY 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. / 2018-2019.

☐ I am not having my voluntary contribution for the academic period 1st Semester, A.Y. 2020-2021.

FREDERICK IVAN DACLIZON

Name and Signature of Student Date Signed
Conforme:

FREDERICK IVAN DACLIZON Date Signed

Name and Signature of Parent/Guardian

Subscribed and sworn to before me this day of for purposes of availing the Free Higher Education.

ID No.: CRN-006-0119-0212-0
Issued by: GSIS
ASUNCION M. VILLOTE
Issued at: Tacloban City, Leyte
OIC - College President

ACKNOWLEDGMENT

This is to acknowledge receipt of the Free Higher Education Contribution Form of _________________________.
Name of Student

MARLISA B. RIÑOS
Registrar Date Signed

*Print 4 copies