Don Mariano Marcos

Don Mariano Memorial

Marcos State State
Memorial University
University
La Union, Philippines
La Union, Philippines
2x2 ID picture with
FREEFREE
HIGHER EDUCATION
HIGHER EDUCATIONAPPLICATION FORM
APPLICATION FORM name tag in white
________
Semester, SY ____________
Semester, SY ____________ background

CAMPUS: o NLUC o MLUC o SLUC oOU

Date of Application:_____________________

Directions: Fill-out by putting a check mark (/) on the appropriate box or by writing the needed
information. Please write legibly.

I. STUDENT INFORMATION
Name __________________________________________________ ID Number: _______________
Complete Home Address: _________________________________________________________________
Sex: o Male o Female Civil Status: o Single oMarried
Contact Number _________________________ E-mail address _______________________________
Course: ___________________________________________ Year Level: _____________________

Type of Student: o New o Continuing o Returning Student

*if NEW, indicate name of school last attended: ________________________________________________
School year last attended: _________________

Are you a recipient of any scholarship/grant? oYes oNo

If yes, write the complete name of the scholarship/ grant and amount of stipend received per semester
___________________________________________________________________________________

II. FAMILY INFORMATION

ESTIMATED FAMILY
NAME OF PARENTS OCCUPATION
INCOME
Father
Mother
Total Monthly Family Income

I hereby certify as to the correctness of the information provided.

__________________________________ ______________________________________
Signature of Applicant over printed name Signature of Parent/Guardian over printed name

Evaluated by:
REMARKS:
__________________________ o Approved
Campus Scholarship Coordinator o Disapproved/ Ineligible
o Second Courser
o Overstaying
Noted by: o With other scholarship (DOH and DA-ATI)

________________________ Date Evaluated: _______________________________

SAS Head

DMMMSU-SAR-F052
Rev. No. 02 (04.07.2022)