APPLICATION FORM (New Student)

DATA PRIVACY CLAUSE: By completing this form, I hereby agree that Mindoro State University, may collect,
use, disclose, and process my personal data for the purpose/s of application for admission, scholarship, or
enrollment. Requests for inspection, amendment, or restriction of records must be in writing and addressed to
the University Admissions Office and must specify the reasons for the request. Mindoro State University
reserves the right to respond appropriately according to law.

General Instructions: Please print in black or blue ink or type all information requested
ENTRY STATUS INTENDED COURSE (Please use program
 Incoming First Year codes below)
 Transferee 1. _____________________________
 Second Degree Taker
2. _____________________________

PERSONAL DATA
Name: (Please use legal name based on Birth or Marriage Certificate) Applicant Number:

LAST FIRST MIDDLE

Civil Status: Sex: Date of Birth: Place of Birth Religion:
 Female
 Male
MM / DD / YYYY
Residential Address: (No./ St./ Subd./ Brgy. / City/ Country)

Telephone No.: Mobile No.: E-mail Address: (please write legibly)

Person to Notify in Case of Emergency: Relationship to Applicant Telephone No./ Mobile No.

ACADEMIC BACKGROUND
Are you a former MinSU Laboratory High School Student?  Yes  No MinSU Student No.:
Name of Current/ Last School Attended: Senior High School Track/ Strand: Current Grade/ Year Level

School Address:

Do you belong to the Upper Percentage of Graduating Class  Yes (Please provide certification)  No
AWARDS/ RECOGNITIONS RECEIVED IN LOCAL/ REGIONAL/ NATIONAL/ INTERNATIONAL COMPETITIONS. (Please attach
photocopy of the certificates received)

CHOOSING MINDORO STATE UNIVERSITY

How did you learn about Mindoro State University?
 MinSU Website  Social Networking Sites  Others (Please specify)
 MinSU Faculty and Employees  Parents/ Relatives/ Friends ________________________
Please state the reason/s why you want to study at Mindoro State University:

******************************************************* PROGRAM CODES ****************************************************************

MAIN CAMPUS (VICTORIA) BONGABONG CAMPUS CALAPAN CAMPUS

101001 BS Agriculture 202001 AB Political Science 302001 AB English
101002 BS Agro-Forestry 204001 BS Computer Engineering 302002 AB Psychology
101003 BS Horticulture 204002 BS Information Technology 303001 BS Hospitality Management
102001 AB English Language 203001 BS Entrepreneurship 303002 BS Tourism Management
102002 BS Environmental Science 203002 BS Hospitality Management 304001 BS Information Technology
103002 BS Entrepreneurship 203003 BS Tourism Management 306001 BS Criminology
103003 BS Tourism Management 205001 B Secondary Education 305001 B Secondary Education
104001 BS Information Technology 205002 B Elementary Education 305002 B Technology and Livelihood Education
105001 B Secondary Education 206001 BS Criminology 305003 B Technical-Vocational Teacher
105005 B Elementary Education 207001 BS Fisheries Education
106001 BS Agricultural & Biosystems
Engineering

Student Center Bldg., MinSU Main Campus, Alcate, Victoria, Oriental Mindoro | Mobile: 09278071202
uao@minsu.edu.ph | www.minsu.edu.ph
 FAMILY BACKGROUND
FATHER MOTHER
 Living  Deceased  Living  Deceased
Full Name:
MinSU Employee? MinSU Employee?
Occupation:  Yes  No  Yes  No
 Married (Living Together)  Annulled  Single Parent
Marital Status:
 Married (Separated)  Widowed  Living-in
Name of Guardian: (if not living with parents) Relationship to Applicant Telephone No./ Mobile No.
Home Address of Guardian: Mobile No. of Parent / Guardian E-mail Address of Parent/ Guardian

Monthly Family Income:  Php 20,000.00 to Php 40,000.00  Php 130,000.00 to Php 200,000.00
 below Php 10,000.00  Php 40,000.00 to Php 80,000.00  above Php 200,000.00
 Php 10,000.00 to Php 20,000.00  Php 80,000.00 to Php 130,000.00

OTHER DATA (If yes, please attach photocopy of certifications of ID

Are you a Person with Disabilities / with Special Needs?  Yes (Please provide certification)  No
If Yes, please provide some details:
Are you a member of an Indigenous Cultural Community/ Indigenous Peoples  Yes  No
Are you a solo parent/ child of a solo parent  Yes (Please provide Solo Parent ID)  No

DECLARATIONS
Do you have any medical condition which may affect your performance in college?  Yes  No
If Yes, please provide certifications stating fit to go to school.

Do you have any mental health-related concerns (psychological, emotional) or other developmental needs which may affect
your performance in college?  Yes  No
If Yes, please provide certifications stating fit to go to school.

AGREEMENT
 I hereby certify that all information supplied in this application is complete and accurate and that I understand and agree that
any misrepresentation or inaccuracy on this form will nullify my application and/or may be grounds for my dismissal and/ or
legal actions against me by Mindoro State University.

____________________________________
Name and Signature over Printed Name

*********************************************************** FOR MinSU UAO ONLY ****************************************************************

REQUIREMENTS CHECKLIST
 Certified True Copy G11 Report Card Optional and if available:
 Admissions Fee Receipt  Medical Certificate (if needed)
 2 copies 2x2 ID picture  PWD ID / Solo Parent ID / Proof of Indigeneity/ Ethnicity
 4Ps Membership
For Transferees/ 2nd Degree Takers  Certified True Copies of Achievement Certificates
 Copy of Grades/ Transcript of Records  Equivalency Assessment and Certification (ALS Completers)
 Transfer Credentials (Transferee)

REMARKS:

Processed by: Date Remarks

Student Center Bldg., MinSU Main Campus, Alcate, Victoria, Oriental Mindoro | Mobile: 09278071202
uao@minsu.edu.ph | www.minsu.edu.ph