Revised 2019 DHVSU-QSP-ADSO-001-FO001-R001

OFFICE OF ADMISSIONS Attach passport size

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APPLICATION FORM
Student Application No: (1.77 In x 1.37 In)

Fill out this form carefully and PRINT or TYPE all information requested. Only Application Forms correctly and completely filled out will be
accepted.
INCOMPLETE FORMS WILL NOT BE PROCESSED. If Item is not applicable indicate “N/A”.

Name (Surname) (Given name) (Middle name) (Ext. Name)

A. PERSONAL INFORMATION
AGE DATE OF BIRTH (MONTH/DATE/YEAR) SEX CITIZENSHIP PLACE OF BIRTH (City) (Province) (Country)
‫ ׮‬MALE ‫׮‬
FEMALE
MOTHERS’S MAIDEN NAME (Last Name) (First Name) (Middle Name) Mobile Number(Required)
+63
FATHER’S NAME (Last Name) (First Name) (Middle Name) Mobile Number(Required)
+63
B. DEMOGRAPHIC DATA
PERMANENT MAILING ADDRESS (Room/Floor/Unit No. Bldg. Name) (House/Lot/Block/Phase No.) (Street Name) (Subdivision)

(Barangay)
(City/Municipality) (Province) (Country) ZIP CODE

HEIGHT (feet)
WEIGHT (kg) CIVIL STATUS
‫ ׮‬Single ‫ ׮‬Married ‫ ׮‬Widowed ‫ ׮‬Legally Separated ‫ ׮‬Single Parent ‫׮‬
MOBILE
NUMBER(Required) Annulled ‫ ׮‬Others TELEPHONE NUMBERS(Include Area Code)
+63 E-MAIL ADDRESS(Required)

Are you a child of a Solo Income per capita:

Are you a member of the
Parent? ‫ ׮‬Yes ‫׮‬ ‫ ׮‬Yes ‫ ׮‬No
Indigenous People’s Community?
No
Are you a Single Parent? ‫ ׮‬Yes ‫׮‬ Are you a member of 4ps? ‫ ׮‬Yes ‫ ׮‬No
C. EDUCATIONAL BACKGROUND No
Level of Education
Course/Degree Title Name of School & If Not Graduated If Graduated
Address
Year of Highest Year Academic Honors
Last Grade/Level/ Graduated Received
(City/Municipality & Province) Attendance Units Earned
Doctorate
Master’s
Tertiary
Vocational / Technical
Senior High school
Junior High school
Elementary
D. CAMPUS LOCATION
‫ ׮‬BACOLOR-Main ‫ ׮‬MEXICO ‫ ׮‬STO. TOMAS ‫ ׮‬PORAC ‫ ׮‬LUBAO ‫ ׮‬CANDABA ‫ ׮‬APALIT
E. TYPE OF
STUDENT
‫ ׮‬Grade 7 ‫׮‬Grade 11 1‫׮‬st Year College ‫׮‬Methods of Teaching ‫׮‬Shiftee ‫׮‬Returnee ‫׮‬Transferee
If Transferee or shiftee, write previous academic program taken:
F. SEMESTER APPLYING FOR
1 ‫׮‬st Semester / Trimester 2 ‫׮‬nd Semester / Trimester 3 ‫׮‬rd Trimester
G. ACADEMIC/DEGREE PROGRAM (Include FIELD OF SPECIALIZATION if applicable)
1st Priority 2nd Priority (College Applicants ONLY)

CONFORME: By signing below, I hereby certify that all the information written in this application are complete and accurate. I agree to update the Office of Admissions and the Registrar’s Office for
any changes. I acknowledge that I have read and understood the Don Honorio Ventura State University (DHVSU) Admissions Privacy Notice posted in the office premises. I understand that by applying
for admission/registering as a student of this university, I allow DHVSU through the Office of Admissions to collect, record, organize, update or modify, retrieve, consult, utilize, consolidate, block, erase
or delete any information which are a part of my personal data for historical, statistical, research and evaluation purposes pursuant to the provisions of the Republic Act No. 10173 of the
Philippines, Data Privacy Act of 2012 and its corresponding Implementing Rules and Regulations. I also agree, if accepted as a student, that my admission, matriculation, legibility for any
assistance/grant, and graduation are subject to the rules and regulations of this institution.
Student’s signature over printed name ____________________________________________________ Date: ______________________________
To be Checked and Signed by the Admission Staff
The applicant presented the following documents:
‫ ׮‬Form 138-A/Report Card ‫ ׮‬Transcript of Records ‫ ׮‬Certificate of grade point average Checked by: __________________________ Date: ____________
‫ ׮‬Certificate of Good Moral ‫ ׮‬Clearance ‫ ׮‬Recommendation Letter
‫ ׮‬PSA Birth Certificate ‫ ׮‬Honorable Dismissal ‫ ׮‬Transcript of Records (TOR) Profiled by: __________________________ Date: ____________
‫ ׮‬Certificate of Eligibility (ALS) ‫ ׮‬NCAE Result ‫ ׮‬CTC of DIPLOMA (For Graduate Program)
‫ ׮‬ESC Certificate ‫ ׮‬Certification: Top 20 of ‫ ׮‬PSA Marriage Certificate Test Permit
the Graduating Batch (For Female Married Applicant) Issued by: ___________________________ Date: ____________

Remarks: