Republic of the Philippines

JOSE RIZAL MEMORIAL STATE UNIVERSITY

The Premier University in Zamboanga del Norte
Dapitan City, Zamboanga del Norte
Contact No: 0946-238-9216 (Smart) 0966-155-0629 (Globe)
main.guidance@jrmsu.edu.ph
GUIDANCE OFFICE

COLLEGE ADMISSION TEST APPLICATION FORM

APPLICATION FORM NO.:MC-23-019446

DIRECTIONS: Please fill out this form honestly and accurately.
I. PERSONAL DATA (Please print)
Name: KWAN DHARYL BARTE
(Family Name) (Given Name) (Middle Name)
Date of Birth: 2005-06-26 Age: Place of Birth: TAGBILARAN BOHOL

Gender: FEMALE Civil Status: SINGLE Citizenship: FILIPINO Religion: RAMAN CATHOLIC

Permanent Home Address: POBLACION SOUTH, PIÑAN, ZAMBOANGA DEL NORTE

Telephone/Cellular Number: 09606667326 Email Address: alicefred545@gmail.com

Disabilities, if any that would require special assistance: ( ) Yes (/) No
IN CASE OF EMERGENCY, PLEASE CONTACT:
Name of Parent/Guardian: DERFECILA R. BARTE Relationship: MOTHER
Occupation of Parent/Guardian: TEACHER Contact No.: 09606667326
Address of Parent/Guardian: POBLACION SOUTH, PIÑAN, 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: ABM
Name of School Last Attended: PIñAN NATIONAL HIGH SCHOOL Year Last Attended: 2023 ( ) Private (/) Public
School Address: POBLACION NORTH, PIÑAN, ZAMBOANGA DEL NORTE Honors Obtained: NONE
III. COURSE PREFERENCE:
Course Applied for:
First Choice: BACHELOR OF SCIENCE IN NURSING

Second Choice: DIPLOMA IN MIDWIFERY

Third Choice: BACHELOR OF SCIENCE IN BUSINESS ADMINISTRATION - FINANCIAL MANAGEMENT

I hereby certify that all information written in this application form are complete and accurate. I certify further that this is my first time to take the College
Admission Test Here in JRMSU. If found to have taken twice or more, the University reserves the right to refuse admission.

MARCH 1, 2023
Date Signature over Printed Name of Applicant

IV. TESTING SCHEDULE

TEST DATE: APRIL 13, 2023 VENUE: CNAHS
ROOM NO.: AVH TIME: 1:00 PM
GUIDANCE OFFICE COPY

Republic of the Philippines

JOSE RIZAL MEMORIAL STATE UNIVERSITY
The Premier University in Zamboanga del Norte
Dapitan City, Zamboanga del Norte
Contact No: 0946-238-9216 (Smart) 0966-155-0629 (Globe)
main.guidance@jrmsu.edu.ph
GUIDANCE OFFICE

COLLEGE ADMISSION TEST PERMIT

APPLICATION FORM NO.:MC-23-019446
DIRECTIONS: Please fill out this form honestly and accurately.
I. PERSONAL DATA (Please print)
Name: KWAN DHARYL BARTE
(Family Name) (Given Name) (Middle Name)
Permanent Home Address: POBLACION SOUTH, PIÑAN, ZAMBOANGA DEL NORTE
Name of School Last Attended: PIñAN NATIONAL HIGH SCHOOL
School Address: POBLACION NORTH, PIÑAN, ZAMBOANGA DEL NORTE
IV. TESTING SCHEDULE
TEST DATE: APRIL 13, 2023 VENUE: CNAHS
ROOM NO.: AVH TIME: 1:00 PM

IMPORTANT REMINDERS
1. Bring Test Permit on Test date and present this to room examineer. Registration Officer:_______________________________
2. Bring at least 2 pencils.
3. Present this permit when claiming results. Signature:_______________________________
4. No cellular phones allowed in the testing room. EXAMINEES COPY