FORM
04
November 07, 2022
APPLICATION FOR COLLEGE ADMISSION
Application No.
OR No. Sem. A.Y. Attach
Date: 2”x2” I.D.
Picture here
PRINT OR TYPE ALL ENTRIES
Family Name Given Name Middle Name
Sex Male Female Age___ Citizenship: _______ Religion Civil Status: ____ Place of Birth: _________
Permanent Address: Date of Birth: _________________________
Street Barangay
_______________________________________________________________ Contact No: __________________________
City/Municipality Province Zip Code E-mail Add: _________________________
Father's Name: Occupation: __________________________
Last Name First Name Middle Name
Highest Educational Attainment: Contact No: __________________________
Mother's Maiden Name: Occupation: __________________________
Lastname First Name Middle Name
Highest Educational Attainment: Contact No: __________________________
Guardian's Name: Occupation: __________________________
Lastname First Name Middle Name
Highest Educational Attainment: Contact No:
Monthly Family Income 10,000.00 and below 10,001.00-15,000.00 15,001.00-20,000.00 20,000.00 and above
COURSE PREFERENCE: (Please indicate your three choices below)
1st Choice: ______________________ major in _________________
2nd Choice: _____________________ major in _________________
3rd Choice: _______________________ major in __________________
CONNECTIVITY QUESTIONS (Kindly answer the questions honestly)
Do you have your internet connection at home? Yes No
What is the service provider of your internet connection (please specify) ______
Do you have your own smartphone with mobile data or internet connection? Yes No
Do you have your own laptop/personal computer (PC) with internet connection? Yes, No
Rate your speed internet connection from 1 to 10 (1 is the lowest and 10 is the highest)
EDUCATIONAL BACKROUND
Type of School
Level School Address Honors/Award
Private/Public
Elementary
Junior High School
Senior High School
Tertiary
Special Courses
I hereby affirm that all information herein are complete and accurate. I am aware that any or all the information furnished in this
application will be checked against original documents and that withholding false information will make me ineligible for admission or
subject for dismissal. If admitted, I agree to abide by the policies, rules, and regulations of Capiz State University.
I further affirm that I have read this form, understood its content and consent the processing of my personal data. I understand that my
consent does not preclude the existence of other criteria for lawful processing of personal data, and does not waive any of my rights under
the Data Privacy Act of 2012 and other applicable laws
Date of Application Signature Over Printed Name of Applicant
Application No.
RETURN SLIP Attach
CAPIZ STATE UNIVERSITY – College Admission For A.Y 2”x2” I.D.
Name: ________________________________________________________________________________________ Picture here
Course:
Date/Time of Exam:
Venue of Examination:
OR No.: Date:
Administering Officer
Note: Bring this slip on the date of the examination. Bring pencils and a ballpen.
Document Type:
Document Code GCO-F01
FORM
ISO 9001:2015 Revision No. 04
Document Title: Effective Date November 07, 2022
APPLICATION FOR COLLEGE ADMISSION Page 2 of 2
ADMISSION REQUIREMENTS:
1. For submission:
Duly accomplished Application for College Admission Form.
A copy of High School Report card duly certified or authenticated by the Principal/Registrar.
Two (2) recent identical passport (2”x2”) pictures, white background /with collar, duly signed at the
back by the applicant.
A photocopy of the applicant’s live birth certificate (PSA).
A photocopy of the certificate of good moral character.
One white folder with fastener and clear white envelope
Medical Laboratory and Drug Test Results
2 Non-refundable Admission Fee of P150.00 (Fist- time college applicants are subsidized by CHED, except second
courser).
3 Only applicants who satisfy the above requirements are eligible to take the CapSU-(CA).
4 The schedule of CapSU- CA examination will be determined by the Admitting Officer.
*Only students who passed the CapSU screening and qualifying examination/ interview will be admitted for
enrollment.
Note: This Application Form is NOT FOR SALE. It can be photocopied/ reproduced.
For details of the CapSU- CA Guidelines and Requirements, please see us or call
Tel. No .
