Republic of the Philippines

Laguna State Polytechnic University

Province of Laguna

APPLICATION FOR COLLEGE ENTRANCE TEST

Instructions: READ ADMISSION AND APPLICATION REQUIREMENTS AT THE BACK PAGE

Fill in all the required information. DO NOT leave an item blank. if item is not applicable, indicate "N/A".

STATUS OF APPLICANT

☑ Freshmen ☐ Transferee ☐ Returnee ☐ Shifter ☐ Continuer

PERSONAL INFORMATION
Name Dugan Ar-jay Paladin P
AGE DATE OF BIRTH SEX CIVIL STATUS CITIZENSHIP
2007-12-12
16 ☑ Male ☐ Female ☑ Single ☑ Filipino
COMPLETE PERMANENT MAILING ADDRESS
(HOUSE NUMBER) (Street/Subdivision) (Barangay) (Municipality/City) (Province) (Zipcode)

389 Sitio Kalawang Brgy Magsaysay Siniloan Siniloan Laguna 4019

Laguna
MOBILE NUMBER TRACK/STRAND INTENDED First Choice: Bachelor of EMAIL ADDRESS
COURSE Science in Industrial
Technology

09678123404 Second Choice: Bachelor of arjaydugan12@gmail.com

Science in Criminology
EDUCATIONAL ATTAINMENT
NAME OF SCHOOL SCHOOL ADDRESS TYPE OF SCHOOL YEAR ATTENDED
ELEMENTARY:
Magsaysay Siniloan Laguna
Magsaysay Elementary School ☑ Public ☐ Private 2012

HIGHSCHOOL:
Kapatalan Siniloan Laguna
Kapatalan National Hig School
☑ Public ☐ Private 2018

SENIOR HIGH SCHOOL:

Kapatalan National High School
Kapatalan National High School ☑ Public ☐ Private 2019

COLLEGE: (For Transferee)

☐ Public From:
To:
☐ Private

Course REASON FOR TRANSFERRING:

RAW SCORE: GWA: GUIDANCE COUNSELOR/GUIDANCE PERSONNEL: DATE FILED:
March 1, 2024
LRN: 108492110015 SIGNATURE OF THE APPLICANT:

Application Number: 156006 LSPU ENTRANCE TEST PERMIT

To be filled-out by applicant
Applicant's Name: Ar-jay Paladin Dugan
Intended Course: Bachelor of Science in Industrial Technology
SCHEDULE OF EXAMINATION

Date: ____________ Approved:

Time: ____________ ___________________________________
Room No: ____________ Examiner's/Proctor's Signature