SAMAR STATE UNIVERSITY

Arteche Blvd., Catbalogan City, Philippines 6700

Office of the University Registrar

SSU-UNREG-FR-002
04-FEB-2019 REV. 4

STUDENT’S PERSONAL INFORMATION

INSTRUCTIONS
1. Write in PRINT the required information completely and neatly. 3. Do not leave any item unanswered. Write N/A on the space when an item if not applicable.
2. Only carefully and completely accomplished form will be accepted. 4. Incomplete form will not be processed
A. PERSONAL DATA
Student Status New Old Returnee Transferee Shiftee
ID Number
First Name Include here (Jr.,II.etc.
Middle Name Religion
Last Name Dialect Spoken at Home
Date of Birth _ _ / _ _ / _ _ _ _ / (MM/DD/YYY) Tribal Affiliation I.D Picture
Place of Birth Gender Civil Status Passport Size with Name
Citizenship ____ Male ___ Single Tag
Contact Number ____ Female ___ Married
Email Address ___ Separated
Nationality ___ Widow(er)
Street Barangay
Permanent Zip code
Municipality Province
Address
Street Barangay
Current Address Municipality Province

B. FAMILY BACKGROUND
*Put + and indicate year of death, for deceased parents, spouse, siblings or children

FATHER MOTHER'S MAIDEN NAME

(First, Middle, Surname) (First, Middle, Surname)
Complete Name
Date of Birth
Place of Birth
Contact Number
Marital Status
Street Barangay Street Barangay
Permanent Address Municipality Province Municipality Province

Educational Attainment
Occupation
Email Address
Estimated Annual Income
Total Family Income
(First, Middle, Surname)
Spouse Name (If married)
Contact Number
Street Barangay
Permanent Address Municipality Province

Occupation
Educational Attainment
DSWD/4Ps Household
Disability & ID Number
Solo Parent & ID Number

Telephone No. +6355 251 2139 | Fax: +6355 543 8394 | Website: www.ssu.edu.ph | Contact us: info@ssu.edu.ph | Follow us on @ssucatbalogan |89 Page 1 of 2
 SAMAR STATE UNIVERSITY
Arteche Blvd., Catbalogan City, Philippines 6700
Office of the University Registrar

SSU-UNREG-FR-002
04-FEB-2019 REV. 4

STUDENT’S PERSONAL INFORMATION

C. EDUCATIONAL BACKGROUND
Enrolled Course Presently
Started SY & Semester in SSU
LRN
___ Public Name of School Year
Elementary Graduated
___ Private Address
___ Public Name of School Year
Junior High Graduated
___ Private Address
___ Public Name of School Year
Senior High Graduated
___ Private Address
___ Public Name of School Year
College Graduated
___ Private Address
___ Public Name of School Year
Graduate Graduated
___ Private Address
Post- ___ Public Name of School Year
Graduated
Graduate ___ Private Address
Last School ___ Public Name of School Year

Attended Address Graduated

___ Private
DECLARATION AND AGREEMENT

I hereby authorize SAMAR STATE UNIVERSITY Registrar’s Office to disclose and share information
provided in my Student Personal Information (SSU-UNREG-FR-002) and my academic information to third parties
outside or to agencies asking for verification for employment purposes either local or abroad, for scholarship,
evaluation, transfer, research, and other legal purposes as may be necessary at their discretion.

This means SSU Registrar’s Office might share information with:

* Other State Universities and Colleges

* Law enforcement, hospitals and other government agencies
* Other Companies whom you have also given consent to share your information

/
Signature Over Printed Name / Date

Telephone No. +6355 251 2139 | Fax: +6355 543 8394 | Website: www.ssu.edu.ph | Contact us: info@ssu.edu.ph | Follow us on @ssucatbalogan |89 Page 2 of 2