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    Republic of the Philippines

    CENTRAL LUZON STATE UNIVERSITY


    Science City of Muñoz, Nueva Ecija
    CLSU TESTING AND EVALUATION CENTER
    Testing Division
    PARENTS/GUARDIAN INFORMATION FORM

    Name of the Child/Applicant


    GABAT, GEE ANNE ALICANTE Applicant ID 2122A04916

    FATHER'SINFORMATION
    Last Name G A B A T
    First Name G U I L L E R M O
    Middle Name S A N T I A G O
    RESIDENCE ADDRESS PERSONAL E-MAIL ADDRESS(IF ANY) CONTACT NUMBER
    Pantoc, Zaragoza, Nueva Ecija None 09982463704
    NATIONALITY RELIGION OCCUPATION
    Filipino Aglipay Farmer
    ESTIMATED MONTHLY INCOME HIGHEST EDUCATIONAL ATTAINMENT
    Below 10,000 High School Level

    MOTHER'SINFORMATION
    Last Name G A B A T
    First Name J U L I E T A
    Middle Name A L I C A N T E
    RESIDENCE ADDRESS PERSONAL E-MAIL ADDRESS(IF ANY) CONTACT NUMBER
    Pantoc, Zaragoza, Nueva Ecija None 09982463704
    NATIONALITY RELIGION OCCUPATION
    Filipino Roman Catholic House Wife
    ESTIMATED MONTHLY INCOME HIGHEST EDUCATIONAL ATTAINMENT
    Below 10,000 College Graduate

    GUARDIAN'SINFORMATION
    Last Name G A B A T
    First Name J U L I E T A
    Middle Name A L I C A N T E
    RESIDENCE ADDRESS PERSONAL E-MAIL ADDRESS CONTACT NUMBER
    Pantoc, Zaragoza, Nueva Ecija None 09982463704
    NATIONALITY RELIGION OCCUPATION
    Filipino Roman Catholic House Wife
    ESTIMATED MONTHLY INCOME HIGHEST EDUCATIONAL ATTAINMENT
    Below 10,000 College Graduate

    FOR CLSU EMPLOYEES ONLY


    NAME OF PARENT EMPLOYED IN CLSU: CLSU EMPLOYEE ID NUMBER:
    Position: College/Unit/Office: Status of Appointment Permanent Temporary Job Order

    PARENT'S PLEDGE, WAIVER AND CONSENT


    I hereby affirm that I have read and understood all the instructions in this application form and that all information written herein are complete
    and accurate. I am aware that any false information furnished in this application form will make me ineligible for admission or subject to dismissal if admitted in the
    university. I give permission to CLSU to store and process my personal data in adherence to the principles of transparency, legitimate purpose, proportionality, data
    quality and academic purposes including but not limited to research as required by RA10173 or Data Privacy Act of 2012.

    Gabat, Guillermo Santiago Gabat, Julieta Alicante


    SIGNATURE OVER PRINTED NAME OF FATHER/GUARDIAN SIGNATURE OVER PRINTED NAME OF MOTHER/GUARDIAN
    ACA.TEC.TED.F.002(Revision No. 4;September 7, 2020)

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