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Republic of the Philippines 


CENTRAL MINDANAO UNIVERSITY 
University Town, Musuan, Bukidnon 

OFFICE OF ADMISSIONS, SCHOLARSHIPS AND PLACEMENT (OASP) 


 
APPLICATION FORM 
UNIVERSITY LABORATORY HIGH SCHOOL ADMISSION TEST (ULHSAT) 
 
Testing Fee: Php 200.00 (Pay at the CMU Cashier’s Office)  Application No.  
O.R. No.        

       
A. APPLICANT    SEX:  Female 
NAME:  Intud  Gianne Xandre N/A  Aguirre 
  (Family Name)  (First Name)  (Middle Name)   
 

BIRTH DATE:  3/14/2007  AGE:   


BIRTH PLACE:  Valencia city​, Bukidnon  RELIGION:  Catholic 
Phase 1 blk 18 lot 4 Sugarland​, Lumbo, Valencia City,
HOME ADDRESS:  ZIP CODE:  8709 
Bukidnon 
SCHOOL NAME:  Valencia City Central School  MOBILE NO.:  09559549962 
SCHOOL ADDRESS:  Poblacion​, Valencia, Bukidnon  LRN:  405077150026 
 

Have you attended a Review?  No  Name of the Review Center:  no 
Name of Review Center in the following Subjects; 
English:    Mathematics:   
Science:    Filipino:   
 

B. FAMILY  FATHER  MOTHER 


FULL NAME:  Intud, Geromy Bon  Aguirre​, Mary Anthonette Derecho 
EDUCATIONAL ATTAINMENT:  College Graduate  College Graduate 
OCCUPATION:  Farmer  N\A 
ANNUAL GROSS INCOME (in Peso)  150000  N\A 
 

C. CERTIFICATION (PRINCIPAL OR SCHOOL DIRECTOR/GUIDANCE COUNSELOR 


I hereby certify that the applicant is [ ] an elementary school graduate [ ] a graduating pupil  
of    SY: __________   

__________________________ ___________ Date: _________________________________ 


Signature Over Printed Name Designation: _________________________________ 
 

D. APPLICANT’S SIGNATURE  E. ACTION TAKEN ​(To be filled up by the CMUCAT Board) 


   I  hereby  certify  under  the  pain  of  perjury  that all my statements  [ ] APPROVED [ ] DISAPPROVED [ ] PENDING 
above  are  true  and  correct  to the best of my knowledge. I consent that   
the  office  of  Admissions  Scholarships  and Placement (OASP) may utilize   
my information in posting of the result and other legal purposes.  _____________________________________________ 
  CMUCAT BOARD 
_____________________________________ Date: _____________   
Signature Over Printed Name  Date: ________________ 
 

NOTE: Subject to revocation if the records upon which the approval is based are found incorrect/invalid 
 
UNIVERSITY LABORATORY HIGH SCHOOL ADMISSION TEST (ULHSAT) PERMIT   
  O.R. No.      Application No.    
 
NAME OF EXAMINEE: Intud​, ​Gianne Xandre N/A​ ​Aguirre   
DATE OF TEST:   TIME:    
PLACE OF TEST: COLLEGE OF EDUCATION       
    LRN:  405077150026       

                 

           CMUCAT BOARD   
  Signature:             
  Note: 1. Present this to the PROCTOR during the exam. 2. No ULHSAT permit: No exam.  Date filed:   
 
 

CMU-F-1-ASP-003  01 June 2015  Rev. 0