PARTIDO STATE UNIVERSITY ParSUCAT APPLICATION FORM Guidance, Admission and Placement Office PSU-F.GAP-01 REQUIREMENT CHECKLIST Two (2) Pieces 1.5" x 1.5"& 1 piece 1" x 1" Psure A Copy of Form 138 (for SHS/HS Graduates) ‘School Certification (fer Greduating SHS Students) ‘Student Personal Record ~ GAP Form 5 Color Coded Folder DATA CONSENT By affixing my sgnatuce below | am allowing the PSU-GAP Office to collet, process ad store the data I have provided in ths application form for the Acnsion Test of the Universty and Yo share the sd data wih UNFAST fer a specified ligitimate purpose Signature over Printed Name /Date EXAMINE NUMBER COLLEGE (for Trasforee/2nd courser only) Name of Schoo! aoe core ‘aaa eR FA one El complete Address Hp code E : in 1513" Eco stone sex Bir Dare atest Peres EM cronctny Bin Pace Religion romped EAE Contact Number E-mail Address Emorooney Peron Comoct Number SENIOR HIGH SCHOOL (where are you completing/completed you Selo High Schoo) FA Nome of Schoo Tock strand EB sasros Yeor Completed B'] JUNIOR HIGH SCHOOL (Whore you completed your Junior High School/High School) Py Name of School ‘Year Completed FE sacres Honors /Award Course Address | cori thatthe above person is « bonafide student of this school year 20. - 20 Further, ths certifies that he/she has a good moral character 1. Aro you differently abled? NO() YES( ) If Yos specify Inclusive Date Head of Schoo! Designation Signature over Printod Nome | contity thot ll the Information in this form is completo and accurate. | undorstand that ell ‘credentials submited in support of mis 2.Aeyouamenbor of any does Popa? NOU) YES() EM cron tncme pear oe try erases ae eee Be acer arncanriseseree 2 Pieseh ee lidelteeiidede Note: List down altleast 3 courses you wish to pursue in the University and a piheyhtleetenh ate Sas oe aR coal cmeniet fou —— ae FAD cones or 3" Choice Ex Signature: EFfecviy Dae: lnwory 2, 2020 fev No 08 Page Tf