Repub Republic of the Philippines

CENTRAL MINDANAO UNIVERSITY

Musu Musuan, Maramag, Bukidnon

(2X2 PICTURE WITH

Office of the National Service Training Program WHITE ROUND NECK
T-SHIRT AND WHITE
STUDENT’S PROFILE
BACKGROUND
SY: 2022-2023
PICTURE.)
NSTP Section: CBM/CAS/CHE/CVM/COA/CFES/CON/COE/CISC/COED Component: ROTC
Personal Information (please fill-up all entries)
Dalisay Ricardo De Leon
Complete Name Last Name First Name Middle Name
Course & Year BSBA – 1st Year Gender Male
Religion Roman Catholic Birthday 11/11/2004 Age: 18
Complete Home Casisang, Malaybalay City, Tel/Mobile No. 09xxxxxxxx
Address (Barangay, Bukidnon
Municipality, Province)
Email Address Dalisaycardo@gmail.com
ZIP CODE
8700 Civil Status Single
Name of Spouse N/A Occupation N/A
Father’s Name Pablo Dalisay Occupation Driver
Mother’s Name Adela Dalisay Occupation Teacher
Name of Person to
contact in case of Adela Dalisay Contact No. 09xxxxxxxx
emergency

Educational Background
Name of School Year Graduated Awards/Honors Received
Elementary

High School

Senior High School

Organization/Involvement (from high school to present)

Name of Organizations/Group Position Year

Skills/Talents/Hobbies (Please check) Involvement in CMU

First Aid/Basic Life Support  Supreme Student Council (SSC)
Writing /Public Speaking College Councils
Counseling Co-Curricular Organizations
Group Handling/Organization Extra – Curricular Organizations
Facilitating  NSRC/CAF
Layout/Designing  Socio-Cultural
Teaching  Red Cross Youth
Singing/ Dancing  Debating Club
Drawing/Sketching   Fraternity/Sorority
Playing Musical Instruments  Others pls specify
Basic Computer
Others, please specify
IN CONSIDERATION FOR MY ADMISSION TO CMU-NSTP, I HEREBY AGREE AND CONSENT THAT THE OFFICE MAY COLLECT,
USE, DISCLOSE AND PROCESS MY PERSONAL INFORMATION SET OUT IN THIS FORM AND/OR OTHERWISE PROVIDED BY ME AS STATED
IN THE DATA PRIVACY ACT OF 2012, FOR SUBMISSION TO CHED FOR ISSUANCE OF SERIAL NUMBER. I LIKEWISE HEREBY CERTIFY THAT
I AM WILLING TO SUBMIT MYSELF TO PERTINENT UNIVERSITY POLICIES, RULES AND REGULATIONS SPECIFICALLY BOOK 3, CHAPTER
12 OF THE UNIVERSITY CODE. I FURTHER CERTIFY TO COMPLY OR SATISFY ALL NSTP TRAINING REQUIREMENTS LAID DOWN UNDER
RA 9163, ITS IRR AND MANUAL OF OPERATIONS. I SWEAR TO PROTECT THE GOOD NAME OF THE CMU-NSTP. I FURTHER SWEAR THAT
THE FOREGOING ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND I AGREE THAT ANY MIS-
STATEMENT OR OMISSION ON MY PART AS TO THE MATERIAL FACT WILL CONSTITUTE A GROUND FOR THE IMMEDIATE DENIAL OF MY
APPLICATION FOR ADMISSION AND I AM WILLING TO BE PENALIZED FOR ANY FALSE ENTRIES MADE. BY SIGNING BELOW, I REPRESENT
AND WARANT THAT I AM THE DATA SUBJECT AND THAT I HAVE READ AND AGREE ALL OF THE ABOVE PROVISIONS.

_______________________
Date Signed: _________ Signature Over Printed Name

CMU-F-1-NST-001 01 June 2019 Rev. 0