form 20 ateneo de davao university addu (04-2014) office of … · 2016. 5. 21. · form 20 addu...
TRANSCRIPT
FORM20ADDU(04-2014)
PreviousEditionObsolete
Application for Admission to Undergraduate Studies
Instructions:1. Filloutthisformcarefullyandprint(inBLOCKletters)ortypeallinformationrequested.2. Submitallrequirementsalongwiththisform.3. Onlyapplicationformsproperlyaccomplishedandsubmittedwiththecompleterequirementswillbeprocessed.4. Onlyapplicationformswithoriginalsignaturesoftheapplicantandtheparents.guardianwillbeprocessed
Suffix
ZipCode ZipCode
EmailAddress
PositionintheFamily(e.g.eldest) No.ofSisters
PARENTS
Father
Mother
Parentsaslistedabove LegalGuardiansName: ___________________________ Agency:_______________________________
FORM20(ADDU04-2014)
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PLEASEDONOTWRITEBELOWTHISLINE
ApplicationFeePaid(DBCAdmissions)ORNo.____________________Amount:___________________Date:___________________Cashier:__________________
CodeRegular Conditional Remarks
Section
TelephoneNo. MobileNo.
ItisthepolicyoftheAteneodeDavaoUniversity,inaccordancewiththeManualofRegulationsforPrivateHigherEducation2008(MORPHE)andtheEducationActof1982,towithholddisclosureofpersonallyidentifiableinformationfromeducationalrecordsunlessthestudenthasconsentedtodisclosureorthelawallowssuchdisclosure.
Bycheckingtheboxesbelow,yougiveconsenttodiscloseyoureducationrecordstoyourparents,legalguardians,andotherdesignedagenciesorgrantinstitutionyouspecify.ThepurposeoftheconsentistoallowtheUniversitytoreleasetheeducationalrecords,awardsandstudentinformation.Thisconsentwillremainonyourrecords.Suchinformationincludesdegrees,grades,courseschedules,disciplinaryrecords,awardsandstudentinformation.ThisconsentwilremainonyourrecordsandallowtheUniversitytoreleaseinformationtoyourparents,legalguardians,andagenciesspecified,evenwhenyouarenolongerlistedasadependentonyourparent'sincometaxreturn,oryouhavegraduatedandlefttheUniversity,unlessyourevokethispermissionbynotifyingtheRegistrar'sOfficeinwritingyourintenttodoso.PleasechecktheboxesbelowtoindicateyourconsentfortheUniversitytodiscloseeducationalrecordsandinformationtoyourparents,legalguardians,andspecificagency:
Parent'sMaritalStatus
NameofSpouse(ifmarried)
InCaseofEmergency(ifboardingorlivingwithrelative,indicatenameoflandladyofguardianaspersontocontact)
PersontoContact Relationship
FamilyBackground
No.ofBrothers
Name Occupation Living ContactNo.
TelephoneNo(s). TelephoneNo(s).
MobileNo.
City/Municipality City/Municipality
Province/Country Province/Country
Subdivision/Sitio Subdivision/Sitio
Barangay Barangay
HouseNo. HouseNo.
Street Street
Gender Religion
ContactInformation
PERMANENTADDRESS CITYADDRESSSameasPermanentBoarding WithRelative
BasicPersonalInformation
Birthdate CivilSatus
Birthplace Citizenship
FirstName 2
MiddleName 3
Ateneo de Davao University Office of Admission and Aid
NameasitappearsontheBirthCertificate Course(s)Appliedforinorderofpreference
LastName 1
Recent1x1
PhotoofApplicant
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HEALTH/MEDICALPROFILE
Ifyes,pleaseindicate:
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DATESIGNED
IMPORTANT:CredentialsfiledinsupportofthisapplicationbecomethepropertyoftheAteneodeDavaoUniversityandwillnotbereturnedtotheapplicant.Misrepresentationofinformationrequestedinthisapplicationwillbesufficientreasonforrefusalofadmissionandexclusion.
IndicateEmailaddressbelow IndicateParent/Guardian'sBillingAddressbelow
APPLICANT'SUNDERTAKING
Iherebycertifythatallinformationwritteninthisapplicationiscompleteandaccurate.Ifacceptedasastudent,Iagreethatmyadmission,registration,andgraduationaresubjecttotherulesandregulationsoftheAteneodeDavaoUniversity.
APPLICANT'SSIGNATURE PARENT'S/GUARDIAN'SNAMEANDSIGNATURE
Pleasesendthruemail Pleasesendthrupostalmail
Ifyes,withwhom: ContactInformation
Brieflydescribeyourreasonforseekinghelp:
PERSONALESSAY
The500-wordessayshouldbeonepagelong,handwrittenonalongbondpaper(page3ofthisform).Topicsselectedatrandomwillbegiventotheapplicantassoonastheapplicationformisfilledout.Theessaymustbewrittenbytheapplicantunassisted.Noparentorguardianisallowedinsidetheessay-writingandinterviewareas.
Preferenceofparent/guardianinreceivingGradeReportCard(selectone)
Listanyhealthproblemsforwhichyouarecurrentlyreceivingtreatment:
DoyouallowtheUniversityIntegratedHealthServicestoconferwithyourphysicianregardingyourcondition?
PSYCHOLOGICALPROFILE
Areyoucurrentlyintherapy,rehabilitaion,orclinicalcounselingelsewhere?
Family/PersonalPhysician'sName
Physician'sContactInformation
Presentlytakingmedication?
AwardsReceivedinHighSchool--AcademicHonors,SpecialAwards,ifany.(pleaseindicatetheawardsreceived,theawardinginstitutionanddate)
BloodGroup Rh
ContactNumbers
GradeSchool
HighSchool
AdditionalInformationforHighSchool
Principal'sName GuidanceCounselor'sName
Primary
EDUCATIONALBACKGROUND
NameofSchool Address YearsAttended
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LEGALNAME:(NameinBirthCertificate) LastName FirstName MiddleName
ESSAYCODE:_____________ START:______________ END:________________
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CLASSIFIEDRECORDS
PERSONALESSAY
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LEGALNAME:
(NameinBirthCertificate) LastName FirstName MiddleName
CommunicationSkills
[]MDART
[]HGART
Composure
[]MDCFD
[]CFD
[]VYCFD
CareerPath
[]UCCRSE InitialObservation:
[]CERTCRSE
InfluenceFactor
[]PRTS
[]PERS
[]INT
[]OT________
InitialRecommendation
[]NTRCMDADM(SendApplicanttoAdmissionsCommittee)
[]RCMDADM
[]RCMDADMPROB
[]RCMDADMFNPROB
BehavioralObservation
[]RCMDGUI
[]RCMDMON
[]RCMDBVPROB NameofInterviewer/Evaluator:
Recommendations
[]RCMDADM
[]RCMDADMWRSVT Program/Department/School
[]NTRCMDADM
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FORINTERVIEWERONLY
IMPORTANT:Afterthispageisfilledout,theformmustnotbeshowntotheapplicantnortoanypartyunlessauthorizedbytheDepartmentChairoranyofhis/herrepresentativeoruniversityadministrator.Theinformationonthispageisclassified/confidential.
Notes:(Pleaseputdateevrytimenewentryisadded)
CLASSIFIEDRECORDS
Date:
Ifonprobation/waitlisted,numberofunitsallowedtobeenrolled:___
CoursestobeexcludedintheRegistrationFormthiscomingsemester: