CATANDUANES STATE UNIVERSITY

CEE APPLICATION FORM

Staple a recent 2”X 2”

photograph (taken within

the last six months) in this

box.

Be sure to print your name

at the back of the photo.

TO THE STUDENT AND PARENTS/GUARDIAN:

Print legibly all information required. Use BLACK BALLPEN. Place X marks in appropriate boxes only. Only accomplished application

forms will be processed.

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. PLACE OF BIRTH: _______________________________________ 5. AGE: ________________________________

6. COMPLETE HOME ADDRESS: _______________________________________________________________________

7. CIVIL STATUS: __________________________ 8. RELIGION: ______________________________________

9. CITIZENSHIP : ________________________ 10. CONTACT NUMBER: _______________________________

11. EMAIL ADDRESS: ______________________________________________

13. HIGH SCHOOL (where you completed/are completing secondary level education):

HIGH SCHOOL NAME: (Do not abbreviate) ________________________________________________________________________

ADDRESS: (City/Town, Province) ________________________________________________________________________________

14. DO YOU HAVE ANY PHYSICAL DISABILITY OR CONDITION THAT REQUIRES SPECIAL ATTENTION OR WOULD MAKE IT DIFFICULT

FOR YOU TO TAKE A REGULAR TEST? ___NO ___YES (specify) ___________________________________________________________

15. SOCIO-ECONOMIC DATA (Furnish all the required information on each family member listed. Write DECEASED after name of

deceased family members. Under the column “Highest Educational Attainment”, indicate the educational level which the household

member actually completed (e.g. Grade II, Third Year High School, High School Graduate, Second Year College, B.S.E., or Ph.D.)

NAME MARITAL

STATUS

HIGHEST

EDUCATIONAL

ATTAINMENT

PRESENT

OCCUPATION

EMPLOYER (Do not leave blank)

GROSS INCOME

(In Phil. Peso)

Father

Mother

(Maiden

Name)

Legal

Guardian

12. COURSES TO TAKE: (List down your first three (3) choices)

1. 1st choice: _________________________________________

2. 2nd choice: _________________________________________

3. 3rd choice: _________________________________________

BROTHERS AND SISTERS:

NAME GENDER MARITAL

STATUS

PRESENT OCCUPATION/

GRADE OR YEAR LEVEL

EMPLOYER/ SCHOOL

ATTENDING

16. Have you applied/are you planning to apply to other schools? ___ No ___ Yes

What are these schools? _____________________________________________________________________________

17. Does anyone from your family an employee of Catanduanes State University? ___ No ___ Yes

Is YES, who and his/her position: ______________________________________________________________________

18. Does anyone from your family an alumnus/alumna of Catanduanes State University? ___ No ___ Yes

If YES, who and kindly indicate what level? (Grade School, High School, College, or Graduate School)

__________________________________________________________________________________________________

I affirm that:

1. All the information supplied in this application form are

true, complete and accurate;

2. I will abide by the Institution’s rules and policies on test

administration and on student fees including tuition,

scholarships, and financial assistance programs.

I am aware that any or all the information in this application may

be checked against the original documents and that withholding

information or giving false information will disqualify me from

admission/will be basis for dismissal, if admitted. I also

understand that no results for my application may be released

until all requirements are satisfied.

_______________________

SIGNATURE OF STUDENT

____________

Date

I certify that:

1. The information which my son/daughter/ dependent

has furnished in this application form is true,

complete and accurate.

I recognize that in signing this application form, I share with

my son/daughter/dependent the responsibility for the

veracity and completeness of the information supplied herein.

_____________________________

SIGNATURE OF PARENT/GUARDIAN

____________

Date

19. Honors/Awards/Distinctions Received: __________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

20. Reasons for applying at Catanduanes State University: _____________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________