(As stated in Birth Certificate. Please PRINT or TYPE.

)
STUDENT APPLICANT Surname

First Name

De La Salle-College of Saint Benilde Antipolo

Admissions & Scholarship Administration Office (ASAO) Middle Name
No. 8 Sen. L. Sumulong Memorial Circle, Brgy. San Jose, Antipolo City
Tel Nos: +63 2 667-1333 and +63 2 667-1334 Nickname
Website: antipolo.benilde.edu.ph

Gender Male Female

Admissions Application Form

(Assigned ID Number once applicant is enrolled)

Submit this form together with all admission requirements indicated in the
Benilde Book for your entrance examination permit and schedule. Only complete
applications will be processed. PRINT OR TYPE YOUR ANSWERS.

2X2
Application is made as a For Academic Year 2019-2020 Colored Picture
(Attach 3 copies,
First Year College student 1st Trimester taken in the last 6 months)
Transfer student 2nd Trimester
2nd undergraduate degree student 3rd Trimester
Others,

PERSONAL DATA
Mailing Address (WRITE LEGIBLY. Mailed application status letters are sent to this address.) Zip Code

Permanent Address Zip Code

Date of Birth (DD/MM/YY) Place of Birth Age Citizenship Civil Status If married, name of spouse

Telephone Number Cellphone Number Email Address Religion

ENTRY INFORMATION (Indicate the degree program you plan to enroll in at Benilde)
DEGREE PROGRAM DEGREE CODE
1ST CHOICE

2ND CHOICE

3RD CHOICE

Are you applying for a Benilde scholarship? NO YES, which scholarship?

Scholarship applications are processed by the Student Grants Office (SGO). Please visit or contact SGO for the details.
Incomplete requirements will not be processed.

DO NOT FILL THIS AREA A B C D BEE CASE NO.

GPA HS FIL HS ENG HS MATH HS SCIENCE HS MKB CND RCMF RANK

AF
Status

DEFICIENCIES:
AAF PIC BC SSR RFP RFC G-11 G-12 PEPT/ALS CF137 CGMC TOR ACR Passport Reason for transfer
OTHERS:

REMARKS:
AAF OR No.: Batch No.:
Date: BEE Date:
Amount: Time:
Remarks: Venue:
FAMILY BACKGROUND (for verification and contact number in case of emergency)

FATHER MOTHER

NAME
CITIZENSHIP
HOME ADDRESS
E-MAIL ADDRESS
TELEPHONE NUMBER

Are you living with parents? YES NO. Please accomplish the Benilde Legal Guardianship Form (Available at the Admissions Center)
Is your father or mother an employee of Benilde? YES NO If YES, who? Father Mother Department/Office

EDUCATIONAL BACKGROUND (Include all schools attended and/or enrolled in)

GRADE SCHOOL NAME AND ADDRESS OF SCHOOL Year Graduated

Grade: 6

JUNIOR HIGH SCHOOL NAME AND ADDRESS OF SCHOOL SY ATTENDED

Grade(s): 7
8
9
10

SENIOR HIGH SCHOOL NAME AND ADDRESS OF SCHOOL SY ATTENDED

Grade(s): 11
12
Senior Track

COLLEGIATE NAME AND ADDRESS OF SCHOOL SY ATTENDED

Year I

Year II
Year III

Year IV

ADDITIONAL INFORMATION: Data collected will be used for research and marketing purposes (optional).
How did you learn about Benilde? (select all that applies to you)

Grandparent Campus Tours/Exhibit Benilde Website Spouse (for married application) Others, please specify
Mother Classmate Newspaper/Magazine Public Events, Expo, Exhibits, Conventions
Father School Counselor Movie/TV/Radio Billboards/Posters/Announcements
Sibling Social Media Career Talk/School Fair Benilde Personnel (Faculty, Admissions Center, etc)
Friend Email Correspondence Online Advertisements Benilde Alumni or current students
Teacher Phone call Brochures/Flyers Colleague or Co-worker (for working applicants)

Have you, at anytime, applied at any College/University/Tertiary School(s)? NO YES (Please answer the questions below)

University/College Name Degree Program Applied to

Top 1

Top 2

Top 3

EXTRA- and CO-CURRICULAR ACTIVITIES/DEPORTMENT

List honors/awards for academic excellence in school or at special events / distinctions received/special talents and skills: (Please accomplish clearly.
Benilde uses this information for merit scholarship screening. Use extra sheet/s if necessary)
List memberships in on/off campus organizations: (Please accomplish clearly. Benilde uses this information for merit scholarship screening.
Use extra sheet/s if necessary)

Were you ever dismissed, suspended or placed on disciplinary probation during your junior/senior high schools and current school for transferees?
Please give details (dates, offenses, penalties): (Use extra sheet/s if necessary)

APPLICATION DISCLOSURES
Is this your first time to apply at Benilde Manila or Antipolo Campus? YES NO (State date of previous application: )

Please indicate your previous application status:

Accepted Not Accepted Wait-listed Others (Please specify: )

De La Salle-College of Saint Benilde, Antipolo Campus aims to provide educational opportunities for diversely-gifted learners including applicants
with special education needs (SEN). The final acceptance or non-acceptance of SEN applicants are based on the merits of their application
and the ability of the College to provide services for their conditions.

It is important to remember, that if you do not disclose, then the College is not obliged to provide you with any support or reasonable accommodation
with regards to your condition and you will be treated as a regular applicant/student. Non-disclosure will also affect your admission to the College.

Do you have physical disability (e.g. heart condition, visual/hearing impairment, etc.), special learning needs (e.g. dyslexia, ADHD, ASD, etc.)
or psychological condition that affected your schooling before and/or may affect your schooling at Benilde?

YES, please specify

(Submit updated Developmental History Form dated within the last six months. For a guide, visit or contact the Benilde Admissions Center)

NO

VERIFICATION / AUTHORIZATION
DE LA SALLE-COLLEGE OF SAINT BENILDE (DLS-CSB), ANTIPOLO CAMPUS hereby understands that information about you is personal.
DLS-CSB Antipolo Campus is committed to protect the privacy of this information as required by the Data Privacy Act of 2012. Because of this
commitment, DLS-CSB Antipolo Campus would need to obtain the individual’s written consent before the College may process the individual’s
personal and sensitive information and has adapted necessary measures to protect it.

I have carefully read the contents of this application form. I certify that the information given herein is correct and complete. Falsification,
misrepresentation, or withholding of information requested in this form will automatically nullify my application and enrollment. I understand that
I will be liable for exclusion from De La Salle-College of Saint Benilde, Antipolo Campus for any falsification, misrepresentation, or withholding
of information employed by me or on my behalf in relation to this application.

I knowingly and voluntarily consent to the disclosure and processing of my personal information and sensitive personal information (disciplinary records
and special need, psycho-emotional condition and physical disability) contained in this application form to De La Salle-College of Saint Benilde, Antipolo
Campus for purpose of assessing my college application. This information will be shared with the members of the admission’s committee.

This also authorizes any school I have previously attended to release any information/records requested by De La Salle-College of Saint Benilde,
Antipolo Campus in relation to this application. The College may use such information in the processing of this application.

Printed Name & Signature of Applicant Date

Printed Name & Signature of Parent(s) / Guardian Date

FOR FIRST YEAR COLLEGE APPLICANTS ONLY:

This is to state that I have never enrolled in any tertiary institution here or abroad after my graduation from senior high school and after taking the Benildean
Entrance Examination (BEE) as part of my application to Benilde.

Printed Name & Signature of Applicant Date

Printed Name & Signature of Parent(s) / Guardian Date

ADMISSION REQUIRMENTS

For First Year College Applicants

Completed Benilde Admissions Application Form

Secondary Scholastic Record issued by the High School’s Registrar (with school dry seal)
Certified true copy of grade 11 senior high school report grades (1st & 2nd semesters)

Two (2) Benilde Recommendation Forms, one from the principal/assistant principal/discipline head and one from the guidance
counselor/homeroom adviser

Three (3) recent identical 2”x2” photographs taken within the last six months
Photocopy of birth certificate issued by Philippine Statistics Authority (PSA)

For applicants who changed schools during junior & senior high schools, a typewritten statement signed by the applicant’s parent(s)
with the applicant stating the reason(s) for the transfer
For applicants who studied abroad, a) Photocopy of Transcript of Records must be authenticated by the Philippine Embassy
of relevant countries of your schooling. If these records are written in a language other than English, complete and official English
translations must be submitted together with the original records. The transcript should indicate all subjects taken and grades
earned. The grading system should be clearly stated in the transcript (present original for verification); b) Photocopy of High School
Diploma or Certificate of Senior High Graduation; c) Certificate of eligibility from Philippine Department of Education (if applicable)

For foreign applicants, photocopy of the following (present original for verification): a) Birth certificate (Household Register/Family
Register); b) Photo, data and stamp of latest arrival page of the passport

For Transferees and Second Degree Applicants

Completed Benilde Admissions Application Form

Certified true copy of Unofficial Transcript of Records (for evaluation purposes)

Certificate of good moral character from the Dean or Vice Dean that the student was not dismissed from the school for disciplinary
reason(s) nor even involved in any case which called for any disciplinary sanction

Four (4) recent identical 2”x2” photographs taken within the last six months

Photocopy of birth certificate issued by Philippine Statistics Authority (PSA)

For applicants who had no more than one year of tertiary education, certified true copy of grade 11 & 12 senior high school report
grades (1st & 2nd semesters)

For transferees who studied abroad, a) Original Transcript of Records must be authenticated by the Philippine Embassy
of relevant countries of your schooling. If these records are written in a language other than English, complete and official English
translations must be submitted together with the original records. The transcript should indicate all subjects taken and grades
earned. The grading system should be clearly stated in the transcript; b) Recommendation letter from counselor/teacher

For second degree applicants only, application letter stating the reason(s) for taking a second degree and photocopy of official
transcript of records (present original for verification)

For foreign applicants, photocopy of the following (present original for verification): a) Birth certificate (Household Register/Family
Register); b) Photo, data and stamp of latest arrival page of the passport

AdC-AF
S. 2018-1