Republic of the Philippines

CATANDUANES STATE UNIVERSITY

Virac, Catanduanes

Control No.: 20____- ____________________________

COLLEGE ENTRANCE ASSESSMENT APPLICATION FORM

(To be filled-out by CatSU Guidance, Counseling and Testing Office Personnel)

ID picture taken within
Date of Examination: _________________________________________________ Time:_________________________ the last 6 months 3.5 cm.
Testing Venue: _______________________________________________________________________________________________
X 4.5 cm (passport size)

With full name tag

(To be filled-out by College Freshmen Applicant/ Transferee) Photocopied picture is

not acceptable
COURSES TO TAKE: (List down your first three (3) choices based on the CatSU Program Offerings)
1st Choice: _________________________________________________________________
2nd Choice _________________________________________________________________
3rd Choice _________________________________________________________________

TO THE STUDENT AND PARENTS/GUARDIAN:

Print legibly all information required. Use BLACK BALLPEN. Place X marks in appropriate boxes only. If not applicable, kindly put N/A. Only
accomplished application forms will be processed.

BASIC INFORMATION:

1. NAME OF STUDENT: Print or type your full name in the following sequence: LAST NAME, FIRST NAME, MIDDLE NAME

Last Name: __________________________________________________________________________________________________________________________________________

First Name:__________________________________________________________________________________________________________________________________________
Middle Name: _______________________________________________________________________________________________________________________________________

2. SEX: Male Female 3. DATE OF BIRTH (Month/Day/Year): - - 4. AGE:

5. PLACE OF BIRTH: _________________________________________________________________________________________________________________________________

6. COMPLETE HOME ADDRESS: ___________________________________________________________________________________________________________________

7. CIVIL STATUS: Single Married 8. RELIGION: __________________ 9. CITIZENSHIP: _______________

Widow/Widower Separated
10. CONTACT INFORMATION:

Permanent Home Address: ________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________
Mobile Number: __________________________________________________ Email Address: ________________________________________
FB Account: __________________________________________________

11. Do you have DISABILITY or CONDITION that requires special attention or would make it difficult for you to take a regular test?

Yes, please specify __________________________________________

No

SCHOLASTIC INFORMATION:

12. SCHOOL LAST ATTENDED: _____________________________________________________________________________________________________________________

13. SCHOOL ADDRESS: _____________________________________________________________________________________________________________________________
14. MONTH AND YEAR OF GRADUATION: ____________________________________________________________________________
15. TYPE OF HIGH SCHOOL: Public Private-Sectarian Private Non-Sectarian
16. SENIOR HIGH SCHOOL GRADES (Grade 12 First Semester):
Subjects Final Grade
English
Mathematics
Science
Filipino
General Weighted Average

CSU-F-GCT-02 Rev. 5 Effectivity Date: November 14, 2022

 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

17. SHIFTERS INFORMATION:

College/University Last Attended: _______________________________________________________________________________________________________________
School Address: __________________________________________________________________________________________________________________________________
Course and Year Level: _____________________________________ General Weighted Average: __________________________
Reason for shifting: ______________________________________________________________________________________________________________________________

CERTIFICATION:

(To be filled-out by your School Head/Guidance Counselor))

GOOD MORAL CHARACTER CERTIFICATION

This is to certify that __________________________________________________, is a graduating student/ graduate of

_________________________________________________________________________________________________________, School Year
_____________________.

This certifies that he/she is possess good moral character and integrity. Records show that his strengths are:
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
3. ____________________________________________________________________________________

Furthermore, he/she [ ] has been subjected to any disciplinary action (please specify)
__________________________________________________
[ ] has not been subjected to any disciplinary action.

Issued this ______ day of __________________, 20_____ for CatSU College Entrance Assessment purposes.

___________________________________________________________________
School Head/Guidance Counselor/Designate
Contact Number: _____________________________

I certify to the completeness and correctness of the foregoing record. [ ] Affixed here is the school dry seal
[ ] This school has no dry seal
______________________________________ Contact Number: ____________
Email Address: _____________
Signature over printed Name

Affix school dry seal here

_______________________________ Date:_______
Position/Official Designation

I affirm that:

1. All information supplied in this application form is true, complete and accurate;
2. I have not taken CatSU Entrance Assessment previously;
3. I will abide by the institution’s rules and policies on test administration, and screening process.

I am aware that any or all the information in this application may be checked against the original documents and I understand that I will be
allowed to take the examination upon the submission of complete requirements.

Furthermore, I understand that all information I provide in this form as well as during the College Entrance Assessment may be used by the
University for research and I believe that my personal details will be treated with utmost confidentiality.

___________________________________ I certify that all information here are true and correct.
Signature of Student
Date: ______________________ ____________________________________________________________
Parent/Guardian’s Signature over Printed Name
Date: ____________

CSU-F-GCT-02 Rev. 5 Effectivity Date: November 14, 2022