Republic of the Philippines

CENTRAL MINDANAO UNIVERSITY University Town, Musuan, 8710 Bukidnon OFFICE OF ADMISSIONS, SCHOLARSHIPS AND PLACEMENT SENIOR HIGH SCHOOL APPLICATION FORM

No.________

SENIOR HIGH SCHOOL QUALIFYING/PLACEMENT TEST 1X1

Testing Fee: P200.00 (Pay at the CMU Cashier’s Office) O.R. No. __________________

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A. APPLICANT NAME ( Print) LAST :

FIRST:

BIRTHDATE:

BIRTHPLACE:

SEX: MALE FEMALE AGE:

MI.

CITIZENSHIP

RELIGION:

HOME ADDRESS: ______________________, _____________________________, __________________ Street No. /Purok/Barangay

Municipality

Province

JUNIOR HIGH SCHOOL COMPLETED:________________________________________________________ SCHOOL ADDRESS:_______________________________________________________________________ Please indicate the track and strand of your choice. Number them as 1 for the first choice, 2 for the second choice and so on. Academic Track: Sports Track: Science , Technology, Engineering and Mathematics (STEM) Basketball Accountancy, Business and Management (ABM) Football Humanities and Social Science (HUMSS) Volleyball c TecVoc Track: Sepak Takraw c Home Economics: Food Processing, Cookery, Food & Beverage Services Track Events c Agro-Fishery: Dairy Production, Swine Production B. PARENTS FATHER:

MOTHER:

EDUCATIONAL ATTAINMENT:

EDUCATIONAL ATTAINMENT:

OCCUPATION: NO. OF CHILDREN IN THE FAMILY:

OCCUPATION:

C. CERTIFICATION (PRINCIPAL OR SCHOOL DIRECTOR) I HEREBY CERTIFY THAT THE APPLICANT IS A JUNIOR HIGH SCHOOL COMPLETER OF____________________________________ SY ___________. __________________________ SIGNATURE OVER PRINTED NAME DESIGNATION ______________

D. ACTION TAKEN [

] APPROVED

[

] DISAPPROVED

_____________________________ CHAIRMAN, BOARD OF EXAMINERS DATE ____________________

CUT ALONG THIS LINE -------------------------------- CUT ALONG THIS LINE ------------------------------- CUT ALONG THIS LINE ------------------------------------

EXAMINATION PERMIT NO. _______ (SENIOR HIGH SCHOOL QUALIFYING/PLACEMENT TEST) 1X1 Recent Photo

NAME OF EXAMINEE ______________________________________________ DATE OF TEST _____________________________________ TIME _________ PLACE OF TEST __________________________________________________ _______________________________ CHAIRMAN, BOARD OF EXAMINERS DATE _______________________

NOTE: Present this permit to the PROCTOR during the exam. NO PERMIT, NO EXAM. Bring Ball Pen. (This form could be reproduced but not to be SOLD.)

CMU-F-1-ASP-011

01 June 2015

Rev. 0