BPSU-SAF-049 (Revision 2, December 2019)

BATAAN PENINSULA STATE UNIVERSITY

City of Balanga 2100 Bataan
PHILIPPINES Recently taken
Passport Size Photo
with Name Tag
BPSU COLLEGE ADMISSION TEST (1 ½” x 2”)

APPLICATION FOR ADMISSION Computer-generated

AY 2021-2022 or photocopied picture
is not acceptable

To the Student: .
Carefully read the GENERAL INFORMATION FOR BPSU-CAT APPLICANTS FOR ADMISSION before filling out this
application form.
IMPORTANT:
ONLY CORRECTLY AND COMPLETELY FILLED OUT APPLICATION FORM – BPSU Form S-001 with other
Aside from this form, bring also the
required documents will be considered for admission purposes.
following:
STUDENT CLASSIFICATION • Certified Photocopy of Grades
General Average • Certified Photocopy of Certificate of
 First Year  Old Returning Student  Lifelong Learner Good Moral Character
LRN • PSA Copy of Birth Certificate
 Transferee  Second Courser • 2 pcs. 1 ½” x 2” photo with nametag

SHS Campus Code Intended Program Code Major Code

Track and Strand

_______
PERSONAL INFORMATION
Name
(PRINT)
(Surname) (Given Name) (Middle Name)

Present
Address (No.) (Street) (Barangay) (Town/City) (Zip Code) (Province)

Permanent
Address (No.) (Street) (Barangay) (Town/City) (Zip Code) (Province)

Date Place  Male

Age Sex:
of Birth
(mm/dd/yyyy)
of Birth  Female
 Single  Legally Married
Name of Spouse:
Citizenship Telephone ____________________
Civil Occupation
Status ____________________
 Widowed  Separated/Divorced
Email Address Mobile Phone  Solo Parent  Common Law/”Live In”
Educational
Attainment
Father’s Name Occupation Socio-Economic Status
(Total Annual Income)
Agency (please check)
Educational
Attainment
Mother’s Name Occupation Below 120,000 120,001-240,000
Agency 240,001-360,000  360,001-480,000
Guardian’s Name
Educational 480,001-600,000  Above 600,001
Attainment
Guardian’s Occupation Religion/Sect:
Contact Number & Agency ________________________
Differently  Communication Disability No. of Sibling/s
 Living together and here in the Philippines  Disability due to Chronic Illness
 Living together but one working abroad Abled Note:
Persons  Learning Disability
 Living together but both working abroad (please check  Intellectual Disability Applicant who belongs to the
 Separated, both without new families type of disability)
 Orthopedic Disability
Indigenous People should check the
appropriate box
 Separated, with new families  Mental/Psychosocial Disability
Marital Status  Solo Parent  Visual Disability  Aeta  Dumagat
of Parents  Widow/er  Other Types, specify:
 Ilongot  Bugkalot
 Kalanguya  Badjao
(please check)  Others, specify ___________________ ___________________  Others, please specify
_______________________
Hand  Left  Both ____________________
Preference  Right
EDUCATIONAL BACKGROUND
Level School Address Inclusive Dates
Elementary
Junior High School
Senior High School
Vocational
College/University Attended
(If graduated,
specify the degree earned)

I hereby affirm that I have read and understood all the instructions in connection with my application
for the BPSU-CAT.
__________________________
Signature of Student-Applicant
I further affirm that all information supplied herein are complete and accurate. I am aware that any or
all of the information furnished in this application may be checked against original documents and that
withholding or giving false information will make me ineligible for admission or subject to dismissal. If __________________________
admitted, I agree to abide by the policies, rules and regulations of Bataan Peninsula State University. Date of Application