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Ateneo de Zamboanga University

APPLICATION FOR COLLEGE ADMISSION


School Year 2013-2014

1x1
PICTURE

Fill out this form carefully and print or type all information requested. Only Application Forms correctly and completely filled out
will be accepted. INCOMPLETE FORMS WILL NOT BE PROCESSED.
1. NAME _______________________________________________________________________
_____________________
Last
First
Middle
Nickname
2. HOME ADDRESS _________________________________________________________________________________________
House No.
Street
Barangay
_________________________________________________________________________________________
City/Town
Province
Tel No. /Mobile No.
If you are from the province, please write the name of your relative living in Zamboanga City and/or your Zamboanga City Address.
Name __________________________________________________________
Address __________________________________________________________
Living Condition:

Family Home
Boarding House

Relation ___________________________
Telephone __________________________

Dormitory
Relatives House
Other: Please specify __________________

3. FATHERS NAME
____________________________________________
If college graduate, from what school? ______________________________
If employed, name of company/employer? _____________________________
If self-employed, nature of work? ____________________________________

Living? Yes ( ) No ( )
Year ________ Degree ______________
Position ____________________________
Name of Company ___________________

MOTHERS NAME _____________________________________________


If college graduate, from what school? ______________________________
If employed, name of company/employer? _____________________________
If self-employed, nature of work? ____________________________________

Living? Yes ( ) No ( )
Year ________ Degree ______________
Position ____________________________
Name of Company ___________________

Parents:

Living Together

Separated

Widowed

SPOUSES NAME (If married) _____________________________________


Family Structure:

Nuclear

Extended

Other __________________

Guardian (If any) _________________________________________________


4.
5.
6.
7.
8.
9.

Occupation _________________________

Occupation _________________________

DATE OF APPLICANTS BIRTH ______________________ Age _________ Place of Birth __________________________


CITIZENSHIP ______________________ Religion __________________ Sex ______________ Civil Status ____________
ETHNIC AFFILIATION: ( ) Visayan ( ) Samal ( ) Zamboangueo ( ) Yakan ( ) Tausug ( ) Others: ____________
LANGUAGES / DIALECTS SPOKEN: _______________________________________________________________________
PRESENT HIGH SCHOOL _______________________________________ Section (Name, Letter or Number) ____________
BROTHERS AND SISTERS EDUCATIONAL ATTAINMENT. Where studying or graduated eldest to youngest.y
Name
Name of High School
Name of College
Year/Course
a. ____________________
_______________________
__________________________ _____________________
b. ____________________
_______________________
__________________________ _____________________
c. ____________________
_______________________
__________________________ _____________________
d. ____________________
_______________________
__________________________ _____________________
e. ____________________
_______________________
__________________________ _____________________
If married, list down the names and ages of your children eldest to youngest.
Name
Age
Grade or Year Level
a. ____________________
_______________________
__________________________
b. ____________________
_______________________
__________________________
c. ____________________
_______________________
__________________________

School
_____________________
_____________________
_____________________

10. SCHOOL ATTENDED: Beginning from the lowest grade, list in order all schools attended. This must be a complete listing of
every school in which you have enrolled.
Elementary
Address
_____________________________
_________________________________ Grade _____ to Grade _____ 20___ to 20___
_____________________________
_________________________________ Grade _____ to Grade _____ 20___ to 20___
High School
_____________________________
_____________________________

Address
_________________________________ Year ______ to Year ______ 20___ to 20___
_________________________________ Year ______ to Year ______ 20___ to 20___

11. Name of the PRINCIPAL or DIRECTOR and GUIDANCE COUNSELOR of your present high school:
Principal _________________________________________ Guidance Counselor ____________________________________

12. List any honors or prizes you have received for scholastic excellence in school or at special events such as science contests,
writing contests, etc. (Indicate honor and year, ex. 2nd Honor, Freshmen; Honorable Mention, Sophomore; Prize won,
sponsoring group, year.)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
13. Are you a candidate for Valedictorian? _______________ Salutatorian? _____________ Honorable Mention? ___________
Other honors (specify) ___________________________________________
14. List your extra-curricular activities, including offices held or special responsibilities and year (ex. Dramatics 1,2,3,4; Class
Treasurer 2,4)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
15. Did you fail in any subject(s) in high school? Give subject(s), date(s) and reason(s)
________________________________________________________________________________________________________
16. Did you ever repeat a year in high school? If so, which year? ______________________________________________________
17. Were you ever dismissed, suspended, or placed on probation by your high school? _____________________________________
Dates, Offenses, Penalties __________________________________________________________________________________
18. PHYSICAL and / or LEARNING DISABILITIES: _______________________________________________________________
19. HEALTH QUESTIONNAIRE: Please answer the following questions:
Do you
a. Smoke?

Yes

No

Have you
f. Been hospitalized for any reason?

Yes

No

If yes, please specify for what reason and current status.

b.
c.
d.
e.

Drink alcoholic drinks?


Have problems falling asleep?
Have memory lapses?
Take any medications?

g. Undergone surgery?
h. Been diagnosed with any chronic medical conditions?
i. Undergone psychiatric assessment or treatment?
If yes, please specify diagnosis, management and current status.

If yes, please specify the medication and for what


condition.

20. Person to contact in case of emergency:


Name: _________________________________________________________
Relationship: ________________________
Complete Address: ________________________________________________________________________________________
Telephone Numbers: Residence: _________________________________
Mobile Phone: _______________________
Place of Employment: ________________________
21. PROGRAMS OF STUDY. Check ( ) the program you wish to follow. Indicate a second choice by placing the number 2 before
the name of the program. Also, make a 3rd choice by placing the number 3 before the name of the program.
_____ AB Economics
_____ AB English
_____ AB Interdisciplinary Studies
_____ AB International Studies
_____ AB Philosophy
_____ Associate in Computer Networking
_____ Bachelor of Arts in Communications
_____ Bachelor of Science in Accountancy
_____ BS Accounting Technology
_____ BS Biology
_____ BS in Business Administration
_____ BS Computer Engineering
_____ BS Computer Science

_____ BS Electronics and Communications Engineering


_____ Bachelor of Elementary Education
_____ Bachelor of Secondary Education
_____ BS Information Technology
major in Web Development
_____ BS Legal Management
_____ BS Management Accounting
_____ BS in Mathematical Sciences
_____ BS New Media and Computer Animation
_____ BS Nursing
_____ BS Office Administration
_____ BS Psychology

22. EDUCATION AND CAREER PLANS.


Did (do) your father or mother, or other members in your family help you in making your educational plans? ______ If yes,
who specifically? __________________. In making your educational plans did you make them first and then discuss with your
parents? _____ . Did your parents made them first and discuss them with you? _____. With whom else have you discussed your
plans? _________________________.
Why have you decided to go to college? (Check as many as you think are true)
To get a liberal education
To prepare for a vacation
To get a job
To be with old school friends
For social enjoyment (College life)
I dont know why
Other. Please specify _______________________________________

For a prestige of a college degree


To make friends and helpful connections
To please my parents/relatives

I hereby certify that all the information written in this application is complete and accurate. I agree if accepted as a student
that my admission, matriculation, and graduation are subject to the rules and regulations of the Ateneo de Zamboanga University.
Students Signature over Printed Name ___________________________________

Date: ______________________________