Type: Document No.

:
QUALITY MANAGEMENT SYSTEM BiPSU-ARO-FM-01
QUALITY ASSURANCE AND ACCREDITATION – FORM Page: 1 of 1
Title: Effective Date: March 1, 2023
ADMISSION APPLICATION FORM Issuance/Revision: 1

DATA PRIVACY CONSENT:

BiPSU Admission and Retention Office collects a variety of information that you provide directly to us. We process your data when necessary to provide you the services that you have
requested where we have obtained with your consent. Without your information, we cannot provide the services you have asked from us. Rest assured that we will treat your
information with utmost privacy and disclose no private information outside the office without your proper consent. As you provided the information below and affixed your signature,
therefore, permission if given.

ADMISSION APPLICATION FORM

( 1st Semester, AY 2023-2024 )

Student Name: SINANGOTE , REGINE ROSOS

( Last Name / Given Name / Middle Name )
Date of Birth(mm/dd/yyyy): 05/05/2004 Age :18 Sex (Male/Female): FEMALE Citizenship: FILIPINO

Complete Home Address: BRGY MAURANG CAIBIRAN,BILIRAN , CAIBIRAN,BILIRAN , BILIRAN , 6565

(Street & Barangay / Town/City/Municipality / Province / Zip Code )
Tel. No. / Cel. No: 09654309348 Email Address: sinangoteregine@gmail.com
Learner’s Reference No: 120810100048 4Ps ID No.: 087804011564700010

Father’s Name: SINANGOTE , ROLANDO ROSAUPAN

( Last Name / Given Name / Middle Name )
Father’s Occupation: FARMER Father’s Contact #: 09709259544
Mother’s Name: SINANGOTE , GINA ROSOS
( Last Name / Given Name / Middle Name )

Mother’s Occupation: HOUSEWIFE Mother’s Contact #: 09709259544

Last School Attended: BILIRAN NATIONAL AGRICULTURAL Academic Status: SHS - HUMSS Grade: 85
HIGH SCHOOL
Person with Disability: NO if YES, Type:

Member of an IP Group: NO if YES, IP Group:

Monthly Net Family Income: LESS THAN PHP 7,890 PER MONTH
Campus: MAIN/NAVAL CAMPUS

Main Campus Degree Program Applied for (1st Choice): BACHELOR OF ELEMENTARY EDUCATION

Main Campus Degree Program Applied for (2nd Choice): BACHELOR OF ELEMENTARY EDUCATION

Biliran Campus Degree Program Applied for (1st Choice):

Biliran Campus Degree Program Applied for (2nd Choice):

Explain your purpose in seeking admission to the institution (school) and what personal objectives do you hope to achieve. Your
statement should reflect both organisations of ideas and language fluency.
I want to help the kids to what i have learn in my skill

CHARACTER REFERENCES. Write down at least 2 names and addresses of persons as character references (e.g. HS Teacher, Guidance Counselor, Brgy.
Official, Priest / Pastor)
Name / Address / Contact Number
09363437030

I understand that my application for admission is subject to the approval of the Admission and Retention Office of the institution. By signing below I certify that
the information given by me is true and correct. I understand that falsifying any of the information is sufficient ground for legal action and rejection of my
application. I understand that should my application be denied BiPSU has no obligation to provide me with a reason for such rejection.

Signature over Printed Name Date

This shall not be reproduced without the permission from the BiPSU-ARO Head. Distribution and use of this Admission
Application Form shall be in accordance with the Control of Documents.