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Republic of the Philippines

Benguet State UniversityOffice of the University Registrar

La Trinidad, Benguet

STUDENT INFORMATION SHEET

CURRENT ACADEMIC BACKGROUND

Course:

This portion will be filled in by the Office of the University Registrar. STUDENT ID Number:

TYPE OF STUDENT: New Old Transferee Cross Enrollee Shifter (Other) _______________________

Semester of entry at BSU: 1st 2nd Summer School year of entry: QCE Rating

PERSONAL BACKGROUND

Family Name: First Name: Middle Name:

Sex: Male Civil Status: Single Blood Type: Religion:

Female Married Citizenship:

Birth Date: (month/day/year) Age: Ethnic Origin:

Birth Place: Provincial Origin:

Address while studying at BSU: Dialect:

Do you stay in: your residential house a Boarding house with relatives in a dormitory

E-mail: Mobile #: Special Skills:

Permanent Home Address:Street no. Sito/Barangay Town/City Province

FAMILY BACKGROUNDName of Father: Living Deceased Telephone / Mobile #:

Address:Barangay Town Province

Occupation: If OFW, indicate where:

Educational Attainment:

Name of Mother: Living Deceased Telephone / Mobile #:

Address:Barangay Town Province

Occupation: If OFW, indicate where:

Educational Attainment:

Monthly Income (in PhP) of the Family: 2,500 5,000 6,000 10,000 11,000 15,000 16,000 20,000 21,000 & up

Name of Sibling/s: List the name/s of your brother/s and/or sister/s, arrange from the eldest to the youngest. Include yourself in the list.

Name Age Birth date Birth Place

CivilStatus

EducationalAttainment

Occupation

1

2

34

5

6

7

8

9

10

11

12

Marital Status of Parents: Parents are married Parents are not married but living together Marriage is legally annulled Single Parent

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Student Information Sheet . Page 2 of 2Marriage is legally annulled Parents are separated (one or both have other partners) Widow/Widower

Information about spouse (if any):

Name of Spouse: Telephone / Mobile #:

Address:

Barangay Town ProvinceOccupation: If OFW, indicate where:

Educational Attainment:

Name of Child/Children:

Name Birth Date Age Birth Place

1

2

Name of Guardian Other than Parents: Telephone / Mobile #:

Address:Barangay Town Province

Person to contact in case of emergency:

Name: Telephone / Mobile #:

Address:

EDUCATIONAL BACKGROUNDElementary School: Year of Graduation: Honor/s Received: /

Address: School Type: Public Private

Secondary School: Year of Graduation: Honor/s Received: /

Address: School Type: Public Private

Post Secondary (Certificate/Diploma/Training Courses)School: Year of Graduation: Honor/s Received: /

Address: School Type: Public Private

Baccalaureate (BS Degree)

School: Year of Graduation: Honor/s Received: /

Address: School Type: Public Private

Masters Degree

School: Year of Graduation: Honor/s Received: /

Address: School Type: Public Private

WORK BACKGROUND

1. Company:

Address: Telephone / Mobile #:

2. Company:

Address: Telephone / Mobile #:

I hereby certify that the above information is true and correct to the best of my knowledge.

_______________________________________________

Students Signature over Printed Name .

Date: ____________________________________________________