2/8/23, 1:48 PM Print Application Form

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 Martinez Jherome Barquilla B
AGE DATE OF BIRTH SEX CIVIL STATUS CITIZENSHIP
10 2012-08-20
☑ Male ☐ Female ☑ Single ☑ Filipino
COMPLETE PERMANENT MAILING ADDRESS
(HOUSE NUMBER) (Street/Subdivision) (Barangay) (Municipality/City) (Province (Zipcode
) )

0817 Purok 5 San Antonio Los Baños Laguna 4030

MOBILE NUMBER TRACK/STRAND INTENDED First Choice: Bachelor of EMAIL ADDRESS

COURSE Science in Criminology
09935945823 Second Choice: Bachelor of jheromemartinez08202004@gmail.com
Science in Agri- Fisheries
Business Management

EDUCATIONAL ATTAINMENT
NAME OF SCHOOL SCHOOL ADDRESS TYPE OF SCHOOL YEAR ATTENDED
ELEMENTARY: Maahas Los Baños Laguma 2017
Maahas Elementary School ☑ Public ☐ Private
HIGHSCHOOL: Umali Batong Malake 2021
Los Baños Los Baños Laguna ☑ Public ☐ Private
SENIOR HIGH SCHOOL: San Antonio Los Baños 2021
Los Baños Senior High School Laguna ☑ Public ☐ Private

COLLEGE: (For Transferee) From:

☐ Public
To:
☐ Private
Course REASON FOR TRANSFERRING:
RAW SCORE: GWA: GUIDANCE COUNSELOR/GUIDANCE PERSONNEL: DATE FILED:
January 5, 2023
LRN: 108309100022 SIGNATURE OF THE APPLICANT:

Application Number: 98478 LSPU ENTRANCE TEST PERMIT

To be filled-out by applicant
Applicant's Name: Jherome Barquilla Martinez Intended
Course: Bachelor of Science in Criminology
SCHEDULE OF EXAMINATION
Date: Approved:
Time:
Room No: Examiner's/Proctor's Signature

https://www.lspuonline.com/print_form/98478 1/1