Form No.

UG-16

DECLARATION AS A NEW STUDENT

In connection with my admission and enrollment at De La Salle University, I declare the following:

1. That I graduated from High School with the following details:

Name of School : ____________________________________________________

Address of School : ____________________________________________________

Month/Year Graduated : ____________________________________________________

2. That I have not registered, enrolled or been admitted at the tertiary level in any school in the
Philippines or abroad;

3. That I have not used or surrendered my High School Report Card, whether original or duplicate, to
another school for purposes of seeking admission at the tertiary level;

4. That the period between my graduation from High School and my admission to De La Salle University
may be accounted for by the following activities:

Month/Year Activity

5. That the details provided in this Declaration as a New Student are true and correct;

6. That I am authorizing De La Salle University to conduct verification procedures to confirm the details
contained in this Declaration as a New Student; and

7. That I understand and agree that any material misrepresentation or inaccuracy contained in this
Declaration as a New Student may be grounds for my dismissal from De La Salle University and/or
legal action against me, at any point during or after my stay at De La Salle University

Student Parent On-Record

Signature over Printed Name Signature over Printed Name

Date Date
**Note: This form must be accomplished in duplicate.

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