CONTROLLED

CONTROL NO.:
Saint Louis University Document Code: FM-OSA-029
OFFICE OF STUDENT AFFAIRS Revision No.: 00
Effectivity: FEB 01, 2021
OSA Student Record Form Page: 1 of 2

IMPORTANT: This form must be accomplished LEGIBLY, COMPLETELY and TRUTHFULLY. However, for any unusual personal
information, please advise the OSA Dean and the University Registrar.

NAME:
(PRINT) Family Name First Name Middle Name

COURSE & YEAR: ID Number:

Classification: Credentials submitted:
( ) Senior High School Graduate ( ) Form 138—Grade 12 Report Card
( ) ALS A & E Test Passer ( ) BALS-ER Form S-2008 SN #:
( ) Returning Student (FORM A): 2” x 2”
( ) Certificate of non-release of F-137A ( )
[A] Undergraduate
[B] Graduate Birth Certificate
PHOTO
( ) Transferee (Aff. / N. Aff) ( ) Certificate of Good Moral Character
( ) Permit Student / Cross-Enrollee ( ) (with NAME TAG; ( ) Transfer Credential
Degree Holder enrollee’s signature ( ) Certified True copy of Grades
( ) Foreign Student
affixed at the back) ( ) CEA (Law / Medicine) ( )
( ) Audit Student / Non-credit ( )
( ) Pre-arranged Scholar ( ) Permit to cross-enroll
( ) Others ( ) Others
For Students with Special Need/Disability: (Please
see OSA Dean for clarification/advice):
GENDER/SEX: ( ) Female ( ) Male BLOOD TYPE:
( ) Medical/ Life Threatening Condition
Civil Status: ( ) Single ( ) Married ( ) Solo Parent
( ) Student with Special Need
Place of Birth: Birth Date: Age: ( ) __ Hearing Impairment /__ Visual Impairment
Citizenship: ( ) Natural-born Filipino ( ) Naturalized Filipino ( ) Physical / Mobility Disability
( ) Dual Citizenship [Filipino and ] ( ) Learning Disability
( ) Autism Spectrum Disorder
( ) Foreign, specifically: ( ) Attention Deficit Hyperactivity Disorder
( ) Ethnicity: ( ) Solo Parent
( )Others:
Religion Professed:
If with the Roman Catholic Religion, please check () if you already received: Clarification:
( ) First Communion ( ) Sacrament of Confirmation

If NO religious affiliation yet: Would you wish to be baptized in the Roman Catholic Church? ( ) Yes ( ) No
Mobile Phone No.: Email Address:
Your ORDER of BIRTH among your siblings: No. out of children.
FATHER’S NAME Occupation: Abroad? Yes/ No
MOTHER’S NAME: Occupation: Abroad? Yes/ No
COMPLETE HOME ADDRESS:

Parents’ Tel./Mobile Phone No.: _______________________________________Email address: _________________________________________

Parents’ Monthly INCOME: _______ __________________________________________________________________________________
Person/s providing financial support for my ( ) school fees, ( ) board and lodging, and ( ) daily allowance
Name/s:
( ) Parent/s ( ) Relative who is my ( ) Non-relative, with address:
GUARDIAN / LANDLORD / LANDLADY IN BAGUIO:
COMPLETE BAGUIO ADDRESS:

Guardian’s/Landlord’s/Landlady’s Tel./Mobile Phone No.: _______________________________________________________________________

FOR SENIOR HIGH SCHOOL GRADUATE:

 JUNIOR HIGH SCHOOL COMPLETED FROM: MUNICIPALITY / CITY:
 SENIOR HIGH SCHOOL GRADUATED FROM: ________________________________________ TRACK: _________________________
 YEAR GRADUATED: (See OSA Dean if you did not enroll in college/technical school within 3 months after Senior H.S. graduation)
 MUNICIPALITY / CITY OF SENIOR HIGH SCHOOL:
 Based on Grade 12 Report Card: No. of Days Absent: No. of Times Late: Homeroom / Conduct:
 Organization/s or Movement/s of which you are or have been a member:
FOR DEGREE HOLDERS / TRANSFEREES / OTHER CASES:
LAST SCHOOL ENROLLED IN (University/College/Technical)
(Enumerate from the farthest to the latest) Course/ Degree Year & Term Attended

• Organization/s or Movement/s of which you are or have been a member:

 CONTROLLED
Saint Louis University Document Code: FM-OSA-029
OFFICE OF STUDENT AFFAIRS Revision No.: 00
Effectivity: FEB 01, 2021
OSA Student Record Form Page: 2 of 2

I certify that the data furnished on this information form as well as the admission requirements submitted are true and
correct. I understand that any concealment/withholding of information in accomplishing this Form or false information/
misrepresentation I submitted in this Form is enough to disqualify and/or invalidate my admission and/or enrolment at Saint
Louis University. If admitted, I promise to uphold the ideals and fully abide by all the rules and regulations of Saint Louis
University and of the Commission on Higher Education as well as the pertinent Laws of the Republic of the Philippines.

By my signature herein, I hereby give my consent to SLU’s collection, processing, and storage of the provided
information pursuant to the provisions of Republic Act No. 10173 or the Data Privacy Act of 2012.

Parent’s / Guardian’s Original Signature Student’s Signature

over PRINTED NAME (if around)

Date of Application

Below to be filled out by OFFICE OF STUDENT AFFAIRS/ADMITTING OFFICER

OTHER REMARKS: ( ) Admitted
( ) Conditionally Admitted
Admitting Officer

Date