Don Mariano Marcos Memorial State University
OPEN UNIVERSITY SYSTEM
San Fernando City, La Union
www.dmmmsu.edu.ph
(072) 242-3608
ous@dmmmsu.edu.ph
https://www.facebook.com/DMMMSUOpenUniversity
____ New student
Latest 2x2
____ Continuing student I.D. picture
____ Returning student REGISTRATION FOR ENROLLMENT FORM (with name tag in
white background)
____ Cross-enrollee
Name: ______________________________________________________________________________________________________
(Family name) (First name) (Middle name)
Program/Course: ______________________________________________ Major: _______________________________________
Mode of Learning: ( ) Group Paced ( ) Self-Paced ( ) Online, name of country: _______________________________
( ) First Semester ( ) Second Semester ( ) Midyear Term School Year _____ to _______
REQUIREMENTS: Original and photocopy/scanned of the following documents
Honorable Dismissal/Transfer Credential PSA Birth Certificate 3 pieces long folder
Official Transcript of Records Medical Certificate with Chest x-ray Certificate of Grades for continuing & returning student
Senior High School Report Card/Form 138 College Admission Test Result 6 pcs. 2X2 I.D. picture with name tag in white backgd
Certificate of Good Moral Character Permit to cross-enroll
Checked by:
________________________________ _____________________________
Admission Officer Program Chairperson
Date of Registration: _________________________
STUDENT INFORMATION SHEET
Name: _______________________________________________________________________________________________
(Family Name) (First Name) (Middle Name)
Date of Birth:_________________ Place of Birth:_____________________________________Age:_____ Gender: _____
Permanent Address: ___________________________________________________________________________________
Contact number: ____________________________ Email address: ____________________________________________
Name of Parents:
a) Father ____________________________________ Occupation ____________________________________
b) Mother ___________________________________ Occupation ____________________________________
Civil Status: __________________________ Citizenship: ________________________
Name of spouse:_______________________ Occupation: ________________________ Number of Children:_________
EDUCATIONAL BACKGROUND:
(Name of School and Address) (Program/Course) (Year Graduated)
Elementary _________________________________________________________ _______________ _____________
Secondary __________________________________________________________ _______________ _____________
College ____________________________________________________________ _______________ _____________
Master’s Degree _____________________________________________________ _______________ _____________
Doctorate Degree ____________________________________________________ _______________ _____________
Others, please specify (e.g. tech-vocational skills) _________________________________________________________
OCCUPATION/EMPLOYMENT:
Position Employer/Address Date of Brief Description of Duties
(Please specify) (Please specify) Employment
__________________ ______________________________ ___________ ________________________________
__________________ ______________________________ ___________ ________________________________
Availability of internet connectivity:
( ) Home with LIMITED internet connectivity ( ) Workplace with LIMITED internet connectivity
( ) Home with STABLE internet connectivity ( ) Workplace with STABLE internet connectivity
PROFESSIONAL EXAMINATION TAKEN:
Title of Examination Date Taken Place of Examination Rating
_______________________________ ______________ __________________________________ ______________
Name and Address of at least two (2) uninterested parties from whom the Open University System can refer to about your
personal circumstances.
Name 1:___________________________________ Address: _________________________________________________
Name 2:___________________________________ Address: _________________________________________________
This is to certify that all the above information is true and valid.
Signature over Name of Student
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