Republic of the Philippines

JOSE RIZAL MEMORIAL STATE UNIVERSITY

The Premier University in the Province of Zamboanga del Norte
Tampilisan, Zamboanga del Norte
Contact No: 0935-691-1975 (Globe)
GUIDANCE OFFICE

COLLEGE ADMISSION APPLICATION FORM

APPLICATION FORM NO.:TC-21-004178

DIRECTIONS: Please fill out this form honestly and accurately.
I. PERSONAL DATA (Please print)
Name: SALUT LESTER KIEFFER BAGO
(Family Name) (Given Name) (Middle Name)
Date of Birth: 2002-10-13 Age: Place of Birth: TAMPILISAN ZAMBOANGA DEL NORTE

Gender: MALE Civil Status: SINGLE Citizenship: FILIPINO Religion: ROMAN CATHOLIC

Permanent Home Address: POBLACION (TAMPILISAN), TAMPILISAN, ZAMBOANGA DEL NORTE

Telephone/Cellular Number: 09754086445 Email Address: Lesterkieffer018@gmail.com

Disabilities, if any that would require special assistance: ( ) Yes (/) No
IN CASE OF EMERGENCY, PLEASE CONTACT:
Name of Parent/Guardian: JUANITA BAGO SALUT Relationship: MOTHER
Occupation of Parent/Guardian: REGISTRAR Contact No.: 09351100548
Address of Parent/Guardian: POBLACION (TAMPILISAN), TAMPILISAN, ZAMBOANGA DEL NORTE

II. EDUCATIONAL BACKGROUND:

Status: (Please put a check mark) (/) K-12 Graduate ( ) Transferee ( ) Returnee ( ) ALS ( ) 4 Years Secondary Education Curriculum ( ) Second Courser

If k-12 Graduate: Track: ☑ Academic ☐ TVL ☐ Arts and Design ☐ Sports Strand: HUMSS
Name of School Last Attended: TAMPILISAN NATIONAL HIGH SCHOOL Year Last Attended: 2021 ( ) Private (/) Public
School Address: POBLACION (TAMPILISAN), TAMPILISAN, ZAMBOANGA DEL NORTE Honors Obtained: WITHOUT
III. COURSE PREFERENCE:
Course Applied for:
First Choice: BACHELOR OF SCIENCE IN CRIMINOLOGY

Second Choice: BACHELOR OF SCIENCE IN AGRICULTURE

Third Choice: BACHELOR OF PHYSICAL EDUCATION

I hereby certify that all information written in this application form are complete and accurate. I certify further that the attached document/s are true and
correct from the orginal copies. If found to have irregularities/discrepancies, the University reserves the right to deny/disapproved the application/admission.

JULY 30, 2021

Date Signature over Printed Name of Applicant