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Admissions Center (As stated in Birth Certificate. Please PRINT or TYPE.

)
STUDENT APPLICANT Surname
2544 Taft Avenue, Manila, Philippines 1004
DE GUZMAN
Tel Nos: (+63) 230-5100 1801 to 1803
Email: admissions@benilde.edu.ph First Name
Website: admissions.benilde.edu.ph RAINIELLE
Office Hours: Mon-Fri. 8:00am-12:00nn Middle Name
& 1:30pm-5:00pm/Sat. 8:00am-12:00nn
CALMA
Nickname
RAIN
Application Form-A Gender Male Female
Submit this form together with all admission requirements indicated in the
Benilde Book for your entrance examination permit and schedule. Only complete (Assigned ID Number once applicant is enrolled)
applications will be processed. PRINT OR TYPE YOUR ANSWERS.
Application is made as a
Freshman student
Transfer student
2nd undergraduate degree student 2X2
Graduate Student Colored Picture
Other, please specify: ____________________________ (Attach 3 copies,
taken in the last 6 months)
For Academic Year ____________________________
2017-2018

1st Trimester
2nd Trimester
3rd Trimester

PERSONAL DATA
Mailing Address (WRITE LEGIBLY. Mailed application status letters are sent to this address.) Zip Code

Permanent Address Zip Code

Date of Birth (DD/MM/YY) Place of Birth Email Address Telephone Number Cellphone Number

Age Height Weight Citizenship Religion Civil Status If married, name of spouse

ENTRY INFORMATION (Indicate the degree program you plan to enroll in at Benilde)
DEGREE PROGRAM DEGREE CODE
1ST CHOICE

2ND CHOICE

3RD CHOICE

Are you applying for a scholarship? NO YES, which scholarship?


Scholarship applications are processed by the Scholarship Grants Office. For requirements and deadlines, go to the Benilde website.
Incomplete requirements are not processed.

DO NOT FILL THIS AREA A B C D BEE CASE NO.

GPA HS FIL HS ENG HS MATH HS SCIENCE HS MKB CND RCMF RANK


AF
Status

DEFICIENCIES:
AF-A PIC BC SSR RFP RFC RFP-P RFC-P PEPT CF137 CGMC F138 ACR Passport GAF AF-B
OTHERS:

REMARKS:
FAMILY BACKGROUND

FATHER MOTHER

NAME

CITIZENSHIP

HOME ADDRESS

E-MAIL ADDRESS

OCCUPATION

TELEPHONE NUMBER

EMPLOYER (Name of Company)

BUSINESS ADDRESS

TELEPHONE NUMBER

HIGHEST EDUCATIONAL ATTAINMENT

LAST SCHOOL ATTENDED

BROTHERS / SISTERS (Please list from eldest to youngest. Please attach additional sheet if necessary.)

NAME AGE CIVIL STATUS SCHOOL YR. LEVEL/YR. GRADUATE

Are you living with parents? YES


NO. For College degree applicants, please accomplish the Legal Guardianship Form
(Available at the Admissions Center)

Is your father or mother an employee of Benilde ? YES NO


If YES, who? Father Mother

Check classification of specified parent


Administrator Faculty Academic Service Faculty
Administrative Service Personnel Others (Pls. specify) ______________________

Is your father or mother a graduate of any De La Salle School? YES NO


If YES, who? Father Mother Both
If YES, Indicate
Father Mother
School _________________________________ _________________________________
Level _________________________________ _________________________________
Course _________________________________ _________________________________
Year graduated _________________________________ _________________________________

WORK BACKGROUND (For working students and graduate school applicants)


Work/Business Information: From the most recent employment to the oldest.
POSITION JOB CLASS* COMPANY NAME AND ADDRESS INCLUSIVE DATES

*Job classification within the company (i.e. Rank and File, Supervisory, Section Manager, Department Manager, Top Management)
EDUCATIONAL BACKGROUND (Include all schools attended and/or enrolled in)

GRADE SCHOOL NAME AND ADDRESS OF SCHOOL SY ATTENDED


Grade(s): 1
2
3
4
5
6

JUNIOR HIGH SCHOOL NAME AND ADDRESS OF SCHOOL SY ATTENDED


Grade(s): 7
8
9
10

SENIOR HIGH SCHOOL NAME AND ADDRESS OF SCHOOL SY ATTENDED


Grade(s): 11
12
Senior Track

COLLEGIATE NAME AND ADDRESS OF SCHOOL SY ATTENDED


Year I
Year II
Year III
Year IV

MASTER NAME AND ADDRESS OF SCHOOL SY ATTENDED

PhD NAME AND ADDRESS OF SCHOOL SY ATTENDED

APPLICATION DISCLOSURES

Is this your first time to apply at Benilde?


YES
NO (State date of previous application: __________________________________________)

Please indicate your previous application status:

Accepted Not Accepted Wait-listed


Others (Please specify: ______________________________________________________)

De La Salle-College of Saint Benilde aims to provide educational opportunities for diversely-gifted learners including applicants
with special education needs (SEN). The final acceptance or non-acceptance of SEN applicants are based on the merits
of their application and the ability of the College to provide service for their conditions.
Do you have physical disability (e.g. heart condition, visual/hearing impairment, etc.), special learning needs (e.g. dyslexia, ADHD,
ASD, etc.), or psychological/emotional condition that may affect your schooling at Benilde?
YES, please specify ______________________________________________
(Submit updated Developmental History Form dated within the last six months. For a guide, visit or contact the Benilde Admissions Center)
NO
EXTRA- and CO-CURRICULAR ACTIVITIES/DEPORTMENT
List honors/awards for academic excellence in school or at special events / distinctions received/special talents and skills:
(Please accomplish clearly. Benilde uses this information for merit scholarship screening. Use extra sheet/s if necessary)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
List memberships in on/off campus organizations: (Please accomplish clearly. Benilde uses this information for merit scholarship
screening. Use extra sheet/s if necessary)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Were you ever dismissed, suspended or placed on disciplinary probation? Please give details (dates, offenses, penalties):
(Use extra sheet/s if necessary)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

ADDITIONAL INFORMATION
Please state your reason/s for applying to DLS-CSB. (Tick all that apply).
Prestige of DLS-CSB Recommended by counselor Recommended by principal
Recommended by teacher Recommended by parents Recommended by friends
Degree programs offered Recommended by sibling / relatives Others (Pls. specify) _____________________
How did you first learn about DLS-CSB? (Tick only one)
Parents In-Campus Tours School Counselors
Sibling / Relatives Print Ads Websites (Pls. specify)
Friends / Classmates High School Teachers _________________________________
DLS-CSB Website Homeroom Advisers Others (Pls. specify)
Career Talks / Career Fairs News Articles _________________________________
Have you, at anytime, applied at any College/University/Tertiary School(s)?
NO YES (Please answer the questions below)
1. Name of School: ____________________________________________________________________________
Degree Program Applied to: ___________________________________________________________________
2. Name of School: ____________________________________________________________________________
Degree Program Applied to: ___________________________________________________________________
3. Name of School: ____________________________________________________________________________
Degree Program Applied to: ___________________________________________________________________

VERIFICATION / AUTHORIZATION
I have carefully read the contents of this application form. I certify that the information given herein is correct and complete.
Falsification, misrepresentation, or withholding of information requested in this form will automatically nullify my application.
I understand that I will be liable for exclusion from De La Salle-College of Saint Benilde for any falsification, misrepresentation,
or withholding of information employed by me or on my behalf in relation to this application.
This also authorizes any school I have previously attended to release any information/records requested by De La Salle-College
of Saint Benilde in relation to this application. The College may use such information in the processing of this application.

_________________________________________________ ________________________
Printed Name & Signature of Applicant Date

_________________________________________________ ________________________
Printed Name & Signature of Parent(s) / Guardian Date
FOR FRESHMEN APPLICANTS ONLY:
This is to state that I have never enrolled in any tertiary institution here or abroad after my graduation from high school
and after taking the Benildean Entrance Examination (BEE) as part of my application to Benilde.

_________________________________________________ ________________________
Printed Name & Signature of Applicant Date

_________________________________________________ ________________________
Printed Name & Signature of Parent(s) / Guardian Date