Saint Bernadette of Lourdes College

#47 Dahlia cor Fairlane Ave., West Fairview Park, Quezon City, PHILIPPINES
Tel. No.: (632) 930-7494 / 938-2504

 
Date of Application:__________________________ Course Applied for:________________________ 

Please check:    _____Freshmen   _____Transferee  _____Second Course 

Name(Please print):___________________________________________  Gender:______ Age:______ 

      (Surname)    (Fiirst Name)  (Middle Name) 

Marital Status:_______________         Date of Birth:_______________         Religion:_______________   

Citizenship:____________       Mobile No.:_____________  Email Address:___________________   

City Address:________________________________________________      Telephone No.:__________ 

Provincial Address:___________________________________________       Telephone No.:__________ 

Name of Father:________________________________________     [  ]  Living    [  ]  Deceased 

Address:_________________________________________________Telephone/Mobile No.:__________ 

Occupation:____________________________    Company:_______________________________ 

Name of Mother:________________________________________     [  ]  Living    [  ]  Deceased 

Address:_________________________________________________Telephone/Mobile No.:__________ 

Occupation:____________________________    Company:_______________________________ 

Name of guardian, if any:__________________________________   [  ]  Living    [  ]  Deceased 

Address:_________________________________________________Telephone/Mobile No.:__________ 

EDUCATIONAL ATTAINMENT: 

Elementary 

School:________________________________________      Address:______________________________ 

Secondary 

School:________________________________________      Address:______________________________ 

Extra Curricular activities/Honor Received:__________________________________________________ 

Last School Attended:____________________________     Address:______________________________ 

Course, if transferee:_________________     Year level:______ School:____________________________ 

Course, if 2nd transferee:________________     Year level:______ School:__________________________ 

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I certify to the correctness of the information given above. 

                ________________________________ 

                           Signature over printed name