Republic of the Philippines

CENTRAL BICOL STATE UNIVERSITY OF AGRICULTURE

Impig, Sipocot, Camarines Sur 4408
Website: www.cbsua.edu.ph
Email Address: cbsua.sipocot@cbsua.edu.ph
Trunkline: (054) 881-6681

OFFICE OF STUDENT
ADMISSIONS
APPLICATION FORM
S/Y 2023 - 2024
Application for: College Application no.

Course applied 1st choice: BSED major in Science 2nd choice: BSED major in English
for:
Learner’s
Student type: Reference 112674100002
Number (LRN):

First name: John Rose Sex Female

Name
Last name: Flores Ext.: Jr.
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I/II/III
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Middle name: Civil status:

Date of birth: November 10, 2004 Place of birth: Tarum, Libaman Cam.
Sur

Religion: Catholic Nationality: Filipino

Contact no: Email
09161607680 johnrose.flores10@gmail.com
address:
Permanent Pos
address: Camambugan Libmanan, Camarines Sur tal 4407
cod
e:

EDUCATIONAL BACKGROUND:
COLLEGE/SENIOR HIGH
ELEMENTAR JUNIOR HIGH SCHOOL
Y SCHOOL
Colegio del Santisimo Rosario, Colegio del Santisimo Rosario,
School Name Camambugan Elementary Inc. Inc.
School
Address Camambugan Libanan Station Church Site, Libmanan Station Church Site, Libmanan
Camarines Sur Camarines Sur Camarines Sur
Year Graduated: 2015 2020
Course/Strand not not applicable
applicable
General Weighted Average
(GWA):

PARENT / GUARDIAN’S INFORMATION:

Name Ag Educational Occupation Contact No.
e Attainment
Father: Joan C. Flores 41 Undergraduate Farmer 09482125962
Mother: Rosalie C. Flores 42 Highschool OFW 09059339523
Guardia Delia C. Flores 61
n:
Spouse:

Average Family Income (Monthly): 10,000.00

Reason/s for choosing CBSUA: Influence by family and friends asude from that CBSUA is already included in my choices.

I hereby certify that the above information is true and correct

Signature Over Printed Name of Applicant Date

ADM-FR-002 Rev.: 1
Effectivity Date: May 2, 2022 Page 1 of 1