Republic of the Philippines President Ramon Magsaysay State Gniversity OP yo Size 1D Picture (Returmee ~ a student not enrolled in the Ink Date of Application: GATE:. [A.. Student's Personal information (To be filled out by the Student-Applicand) NAME: Family Name Fist Name Middle Name ADDRESS! (Barangay) (Micali) (Province) (Zip Code) Contact Number (Required): Email Address (Required) Date of Birth Age: Gender: Place of Birth Gwvi Status( )Solo Parent (Married ( ) Single ( ) Widow Nationality: Religion: ParenvGuardian Relation to Guardian ‘Address of Guardian: (Contact No, ‘Occupation of Parent Guardian: ‘Average income of the Fal TE tesstranio000 [J 10900%620000 [-] 2000t% 20000 © []s0,001 wo so,000 TE) rere nan 50.000 [=] mere tran 10.000 ‘OTHER IMPORTANT INFORMATION: Kindly check the box applicable to you. [_] PWD Indigenous Peoples (1p) — [—] Student from Depressed Areas ‘Ade! information relevant to answer: B. Last Term of Attendance at PRMSU / Course you intend to take at PRMSU: Last term attendance at PRMSU: _‘Term/Semester: Academic Year: Course: Major: Curiculum Year: ‘Are you going to enrol in your previous course taken at PRMSU: ( ) Yes Ono answers NO, what course are you going to take up: lease accomplish / present a copy of PRMSU-ASA-OURSF 3 (Shifting Form), and submit together with tis form. DATA SUBJECT CONSENT FORM In camplance with RA 10173: Data Privacy Act (OPA) of 2012 and its implementing Rules and Regulations (RR, | authorize PRESIDENT RAMON MAGSAYSAY STATE UNIVERSITY to collect ang process my personal information with vtmst confidently. only llow PRMSU to disclose my personal information to afflstes and awful thir partes for legimate purposes only 2 | personaly specie below: [Cschotaship Grantors [=] senetators [employers [—] Researchers [—] Former schoo! [—] industries, Companies, Fs Colunrast [others pease Speci Iikewse rant PRESIDENT RAMON MAGSAYSAY STATE UNIVERSITY (ocollet, proces an sclose my persona Information fora period of ve (5 years ony “Siarature over printed name of Applicant Date ‘Action Taken: ‘Approved Disapproved. Consitional Printed Name ofthe Accepting Dean «Signature ofthe Accepting Dean CREDENTIALS SUBMITTED: To be checked and signed by the Registrar's personnel { ) Certificate of Registration (last trm of attendance at PRIMSU, original or photocopy) ee (Updated Evaluation Form / Program of Study reflecting all subjectscourses credited, photocopy) ‘Signature over printed name {() Clearance trom lat term of atlendance at PRMSU orginal copy) ‘of Applicant {() One (1) Passpor size 1D Picture - (ih colar, white background) ~forretumoes nt onolod at PRMUSU in tho lst 2 yous [NOTE the credentials | submitted are confirmed tobe spurious, my admision wil be revoked. Date admitted, agree to abide bythe polices, rules and regulations ofthe President Ramon Magsaysay State University. () Credentials submitted are complete () Credentials submitted are Incomplete. Please accomplish and submit Form 12-A (Promisory Note) together with this [Recommended for Enrolment ‘Signatur over printed name of Registrar Personnel NoTED: EDGAR R. PASTORES Campus Registrar, tba Campus TolPages ‘Name of Forms ede Version: 02 | Apri 28,2024 Tort Envoiment Form 2.6 (Relurnees) PRMSU-ASA-OURSF 2-6