Republic of the Philippines

DALUBHASAAN NG LUNSOD NG SAN PABLO 1x1 picture

Barangay San Jose, City of San Pablo with
ALCUCOA REACCREDITED Level 1 complete
Unified Student Financial Assistance System for Tertiary Education name
Student No.: 18-0825 REGISTRATION FORM Application No.:

FOR: 1st Sem 2nd Sem Midyear LRN:

PROGRAM APPLIED
Bachelor of Science in Psychology A.Y. _______2020-2021_________ (for new students only)
Instructions: Read General and Documentary Requirements. Fill in all the required information. Do not leave an item blank. If item is not applicable, indicate “N/A”.
PERSONAL INFORMATION

NAME (Last Name) (First Name) Middle Name Maiden Name (for married woman)
REYES JANE LOUIESSA PEÑAFLOR

Date of Birth 0 8 9 Permanent Mailing Address/ San Francisco Calihan San Pablo City
(MM/DD/YYYY) / 2 1 / 1 9 9 Zip Code Laguna
4000
Age 21 Mobile Number 0 9 1 5 9 6 5 5 6 9 7
Place of Birth San Pablo, Laguna E-mail Address reyesjane021@gmail.com
Sex Male Female Nationality FILIPINO
Name of MANUEL A. REYES Relationship Occupation
Parent/Guardia FATHER MAINTENANCE MANAGER
n
Civil Status: Student Type Are you enjoying other Are you a member of any indigenous group?
Continuing Old educational/ Yes or No
 Single Regular Irregular financial assistance? Pls. specify_______________________
 Married New Enrollee Are you a solo parent?
Yes or No
 Widowed Returning Student Yes or No
If yes, please specify:
 Separated Yes No Are you a person with disability?
__________________________
Yes or No
_

SCHOOL RECORD
Intermediate San Pablo Central Elementary School Year Graduated 2012
Senior High School Grant Institute of Trade and Technology Year Graduated 2018
College Dalubhasaan ng Lungsod ng San Pablo Year Graduated
Highest Year Completed SENIOR HIGH SCHOOL
Last School Attended Dalubhasaan ng Lungsod ng San Pablo
COURSES ENROLLED
No. Course Code Course Description Units Time Days Section Instructor
1 NAT SCI E3 Lab 2 9:30 - 11:00 MW PSYC 3B
2 PSY 8 3 12:30 - 2:00 MW PSYC 3B
3 SOC ARTS 3 2:00 - 3:30 MW PSYC 3B
4 PSY 10 3 3:30 - 5:00 MW PSYC 3B
5 PSY 11 3 5:00 - 6:30 MW PSYC 3B
6 PSY 9 3 12:30 - 2:00 TTH PSYC 3B
7 NAT SCI E-3 Lect 3 2:00 - 3:30 TTH PSYC 3B
8 PSY 9 3 3:30 - 5:00 TTH PSYC 3B
Total Number of Units
Note: To be filled out by Finance Officer
Student Type: ____ Resident ____ Non-Resident
I HEREBY CERTIFY that all information indicated in this form and on the Amount
documents attached in this application for free tuition 2017 program are true Tuition fee
and correct and that any concealment or misrepresentation of facts therein Other School Fees
found will adversely affect my application. Registration Fee 100
Likewise, I am fully aware that DLSP may share such information to Guidance Fee 100
affiliated or partner organizations as part of its contractual obligations, or Medical/Dental Fee 100
with government agencies pursuant to law or legal processes. In this regard, I Athletic Fee 100
hereby allow DLSP to collect, process, use and share my personal data in the Library Fee 100
Development Fee 100
pursuit of its legitimate academic, research, and employment purposes
Computer Fee 500
and/or interests as an educational institution. Laboratory Fee 100
Entrance Fee 100
_____________________________________ Admission Fee 100
(Signature over Printed Name of Applicant) Student Handbook 100
Cultural Fee 100
__________________ I. D. Fee 50
Date Accomplished NSTP Fee 150
Graduation Fee 1,500
Form No.: DLSP-SCO-UNI–01 Revision No.: 01 Effectivity Date: December 31, 2019 Page 1 of 1
Approved by: Total Fees
Assessed: Certified:

MS. VRENALI R. TOLENTINO DR. FLERIDA AQUINO LAYBA Benjamin F. Maghirang Elibert O. Singson
Registrar II Dean Account Officer Cashier I