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)
