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INDIVIDUAL INVENTORY FORM

DISCLAIMER
Theinformationprovidedaretrueandaccuratetothebestofyourknowledge.Youalsoagreethattheinformationprovidedherewith,was
preparedonyourownfreewill,freelyandvoluntarilywithoutanyinducement,assuranceorguaranteebeingmade.Youherebyattesttothe
completenessandaccuracyofalltheinformationyouhavegiven.
Further,youarealsoallowingtheUniversitytouseandreleasetheinformationforlegitimatepurposes.Likewise,youpermittheUniversity
toreleaseinformationonlytoauthorizedpersonnelfortheabovestatedpurposeinaccordancewiththeDataPrivacyPolicyoftheUniversity.

YouareawarethatanyactofdishonestyorfalsificationwillleadtoforfeitureofyourapplicationordismissalfromthisUniversity.Theinstitution
mayalsotakefurtherlegalstepsagainstfraudulentactionsifthesituationdemands.

COURSE : BSED MATH

Please fill up the following information below. Rest assured that all information will be treated with confidentiality. Thank you for your cooperation.

PERSONAL INFORMATION:

NAME: (LAST NAME, FIRST NAME MIDDLE NAME) NICKNAME:

Hermanes, Leonardo, Quindoza. Leyo
PRESENT ADDRESS:
Blk 26 Lot 14 Dilang 1 Pinagbuhatan Pasig City
PROVINCIAL ADDRESS:
Marinduque
DATE OF BIRTH: PLACE OF BIRTH: BIRTH ORDER: NUMBER OF SIBLINGS:
May 28, 2001 Pasig City 3rd 8
AGE: GENDER: CIVIL STATUS: RELIGION: NATIONALITY:
19 Men Single Roman Catholic Filipino
HOME PHONE NO.: MOBILE NO.: EMAIL ADD:
09531385525 639683403467 leonardohermanes123@gmail.com
WEIGHT: 55 HEIGHT: 4'11 BLOOD TYPE:

HOBBIES / INTEREST: Basketball TALENTS: Dancing

IN CASE OF EMERGENCY, PLEASE NOTIFY: RELATIONSHIP:

Virgilio C. Hermanes Father
ADDRESS: CONTACT NO.:
Blk 26 lot 14 Dilang 1 Pinagbuhatan Pasig City 09977786334

FAMILY BACKGROUND:
FATHER: MOTHER:
Virgilio C. Hermanes NAME: Emiliana Q. Hermanes

52 AGE: 51

RIZAL TECHNOLOGICAL UNIVERSITY REV=0 EFFECTIVITY:SEPTEMBER1,2015

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Vocational Grad HIGHEST EDUCATIONAL ATTAINMENT: High school Undergraduate
Driver OCCUPATION: House wife

10,000 AVERAGE INCOME PER MONTH: 0

09977786334 CONTACT NUMBER/S: 09977786334

STATUS OF PARENTS:

(/ ) MARRIED &LIVING ( )LEGALLY ( )LIVINGIN(NOT ( ) MOTHER(WIDOW) ( )FATHER(WIDOWER)

TOGETHER SEPARATED MARRIED)

( )SEPARATED [ ]Fatheriswithanotherfamily [ ] Mother is with anotherfamily

RIZAL TECHNOLOGICAL UNIVERSITY REV=0 EFFECTIVITY:SEPTEMBER1,2015

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ACADEMIC INFORMATION:

LEVEL NAME OF SCHOOL YEAR GRADUATED AWARDS RECEIVED

Nagpayong Elementary School 2009-2010

ELEMENTARY:
Nagpayong High School 2014-2015
JUNIOR HIGH SCHOOL:
SENIOR HIGH SCHOOL: 2019-2020
TRACK: Academic Arellano University
STRAND: HUMMS

Subjects interested to: Math

Organization Membership: Pasig Youth Movement

How is your studies financed?

Isyourpresentcourse/programyourpersonalchoice? [/]YES [ ]NO

If NO,

A. Who influenced you?

B. How do you feel about the course not being your first choice?

C. What is your personal choice?

Why did you choose to enroll in RTU?

[ /] Quality education [ /] Free tuition [ ] Competitive FacultyMembers
fee
[ /] Good facilities [ /]Proximityandaccessibility [ ]Performanceinthelicensureexamination
[ /]Recommendedbyfriends,relatives,etc. [/ ] Good reputation [ ] Others, pleasespecify:

What other school do you consider?

[ ]JRU [ ]PUP [ ]UMAK [ ] STI [ ]AMA [ ]ABE
[ ]EARIST [ ]ARELLANO [ ]PNU [ ] Others, please specify:

BEHAVIOR INFORMATION:

Checkifyoueverexperiencethe
When did it happen? Doesitstillbotheringyou?
followingconcerns:
[ ] Bullying [ ]YES [ ] NO
[ ] Suicidal thoughts [ ]YES [ ] NO
[ ] Suicidal attempts [ ]YES [ ] NO
[ ] Panic attacks [ ]YES [ ] NO
[ ] Anxiety [ ]YES [ ] NO
[ ] Depression [ ]YES [ ] NO
[ ] Self / Anger Management [ ]YES [ ] NO
Issues
[ ] Recurring negative thoughts [ ]YES [ ] NO
[ ] Low self-esteem [ ]YES [ ] NO
[ ] Poor study habits [ ]YES [ ] NO
[ ] Poor in decision making [ ]YES [ ] NO
[ ] Impulsivity [ ]YES [ ] NO
[ ] Poor sleeping habits [ ]YES [ ] NO
[ ] Loss of appetite [ ]YES [ ] NO
[ ] Over-eating [ ]YES [ ] NO
[ ] Poor hygiene [ ]YES [ ] NO
[ ] Withdrawal / Isolation [ ]YES [ ] NO

RIZAL TECHNOLOGICAL UNIVERSITY REV=0 EFFECTIVITY:SEPTEMBER1,2015

 [ /] Familyproblem [/ ] YES [ ] NO
[ ] Otherrelationshipproblems [ ] YES [ ] NO
[ ] Alcoholaddiction [ ] YES [ ] NO
[ ] Gamblingaddiction [ ] YES [ ] NO
[ ] Drugaddiction [ ] YES [ ] NO
[ ] Computeraddiction [ ] YES [ ] NO
[ ] Sexualharassment [ ] YES [ ] NO
[ ] Sexualabuse [ ] YES [ ] NO
[ ] Physicalabuse [ ] YES [ ] NO
[ ] Verbalabuse [ ] YES [ ] NO
[ ] Pre-maritalsex [ ] YES [ ] NO
[ ] Teenagepregnancy [ ] YES [ ] NO
[ ]Abortion [ ] YES [ ] NO
[ ] Extra maritalaffairs [ ] YES [ ] NO

PREVIOUS PSYCHOLOGICAL CONSULTATIONS

HaveyouconsultedaPSYCHIATRISTbefore? [ ] YES [ /] NO
If YES, for what reason? When?
Have you consulted a PSYCHOLOGIST before? [ ] YES [/ ] NO
If YES, for what reason? When?
Have you consulted a COUNSELOR before? [ ] YES [ /] NO
If YES, for what reason? When?

PERSONAL DESCRIPTION (Tell something about yourself)

My name is Leonardo Q. Hermanes, i'm 19 years old and i live in nagpyong pinagbuhatan pasig city and my hobby is playing a basketball and
watch the movie and i have a 4 sister and 3 brother's and my father is a driver and my mother is a house wife

DATA PRIVACY CONSENT

ByacceptingthisDataPrivacyStatement,I(as“DataSubject”)grantmyfree,voluntaryandunconditionalconsenttothecollectionand
processingofallPersonalDatatotheinformationdatabasesystemoftheRizalTechnologicalUniversitybywhatevermeansinaccordancewith
RepublicAct(R.A.)10173,otherwiseknownasthe“DataPrivacyActof2012”oftheRepublicofthePhilippines,includingitsImplementingRules
andRegulations(IRR)aswellasallotherguidelinesandissuancesbytheNationalPrivacyCommission(NPC).Ialsoconsenttothefollowing:
1. TheUniversitymaycollectpersonaldataduringmyapplicationforadmissionpurposes.
2. MypersonalinformationcanbeaccessedandusedonlybyauthorizedpersonnelandofficialsconnectedtotheUniversityforlegitimatepurposes only.
3. TheUniversitymayshareordisclosesomeofmypersonalinformationtoothersinitsprocesstodelivernecessaryservicesforthestakeholdersand
theinstitution,includingbutnotlimitedto:
a) webpostingoftheRTU-CollegeAdmissionTest(RTU-CAT)results.
b) webpostingofRoomAssignmentsforRTU-CAT.
c) webpostingpertinenttoadmissionandenrolment.
d) sharinginformationforaccreditationpurposes(AccreditingAgencyofChartered CollegesandUniversitiesinthePhilippines(AACCUP).
e) conductingresearchorsurveysforpurposesofinstitutionaldevelopment.
f) allguidanceandcounseling-relatedfunctionsandservices.
g) otherlegitimateprocessesoftheUniversity.
Iherebydeclarethatalltheinformationprovidedduringmyapplicationaretrueandaccuratetothebestofmyknowledge.Iherebyattest
tothecompletenessandaccuracyofalltheinformationthatIhaveprovided.
IamfullyawarethatanyfalseinformationprovidedmayleadtomyautomaticdismissalandIwillcomplywithallthetermsandconditions set by
yourUniversity.

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