Form No.

UG-04
Office of Admissions
and Scholarships

APPLICANT INFORMATION SHEET

Reference Number AY 2 0 1 8 - 1 9

*Please print all information requested.

APPLICATION DETAILS
Application Type (Check one answer only)
Filipino Citizen including those who are Dual Citizens (Php 600.00)

Non-Filipino Citizen (Php 2,500.00)

Graduating or Graduate of Philippine Public/Science High School (FREE)

Degree Program Choices (Choose preferred campus)

First Choice DLSU Manila DLSU-STC
Second Choice DLSU Manila DLSU-STC

Third Choice DLSU Manila DLSU-STC

PERSONAL INFORMATION
Applicant Name (Please use legal name as it appears on your birth certificate)
Last Name Nick Name
Given Name
Middle Name

Date Of Birth MM/DD/YYYY

Place Of Birth

Gender Civil Status

Religion
Country Of With Dual Citizenship:
Country Of Secondary
Citizenship Citizenship

Phone Number: Mobile Number:

Country Code / Area Code / Number Country Code / Area Code / Number

Primary E-Mail Address

(Please write legibly)

Address (Please write address as it would appear on a letter envelope).

Unit Address
Unit Number Name Of Apartment/Townhouse/Condominium Building

Street Address
Number Street Name Subdivision Name Barangay

District/City/Province
District City/Town Province Region/Estate

Country Postal Code

2401 Taft Avenue, 1004 Manila, Philippines I Tel: (632) 523-4230 | Trunk Line: (632) 524-4611 loc. 166
admissions@dlsu.edu.ph I www.dlsu.edu.ph
Office of Admissions
and Scholarships

ACADEMIC INFORMATION
Last High School Attended School Year Attended
School Name -
Address
Senior High School Track

DECLARATIONS
Do You Have A Physical Condition Which May Affect Your Performance In College?

Yes, if yes please state the physical condition:

No

Do You Have A Behavioral Condition Which May Affect Your Performance In College?
Yes, if yes please state the physical condition:

No
Have You Been Subjected To Any Disciplinary Action?

Yes, if yes please state the disciplinary action:

No

CERTIFICATION
I certify that the information given herein is correct and complete. Falsification or withholding of
information on this form will automatically nullify my application and/or subject me to
dismissal/expulsion from the University.

Signature over Printed Name Date

2401 Taft Avenue, 1004 Manila, Philippines I Tel: (632) 523-4230 | Trunk Line: (632) 524-4611 loc. 166
admissions@dlsu.edu.ph I www.dlsu.edu.ph