Republic of the Philippines
CENTRAL LUZON STATE UNIVERSITY
Science City of Muñoz, Nueva Ecija
OFFICE OF ADMISSIONS
ENROLLMENT FORM
PERSONAL INFORMATION
SANTIAGO HARLEY DAVIDSON CLSU CAT Applicant ID
Name 24-05445
QUIMING No
Family Name Given Name Middle Name
Sex M Civil Status single Nationality Filipino Religion Born Again Christian
Date of Birth December 18, 2005 Place of Birth Science City of Muñoz Health center
Month Day Year City/Municipality Province
Telephone/Mobile No. 09946511482 / E-mail Address harleydavidsonqsantiago@gmail.com
Home Address 0083, BANTUG
House No. Street/Subdivision Barangay
SCIENCE CITY OF MUÑOZ, NUEVA ECIJA,3119, Philippines
City/Municipality Province Zip Code Country
EDUCATIONAL BACKGROUND
Name of School Date of Completion Honors/Awards Received
Elementary CLSU DepEd elementary Lab. School 2017 Grade 5 With Honors
Junior High School Caanawan National high school 2021 None
Senior High School Munoz National high School (SHS) MAIN 2024 WITH HONORS AND COMPLETE ATTENDANCE
College, Institute or University Last attended (if any)
FAMILY BACKGROUND
Father Mother
Name SANTIAGO, NOVO, REY SANTIAGO, MARICEL, QUIMING
Highest Educational Attainment College Level College Level
Occupation Non-Employed Non-Employed
Telephone/Mobile No. 09123004522 09123004522
Brgy. Bantug, Science City of Muñoz, Nueva ecija, Philippines / Brgy. Bantug, Science City of Muñoz,
Address of Parents/Guardian
Nueva ecija, Philippines
STUDENT'S PLEDGE, WAIVER and CONSENT
In consideration of my admission to the Central Luzon State University, I hereby promise and pledge to conform to and abide by all the rules and
regulations laid down by the authorities in the said University and I hereby voluntarily and freely state, without any force or intimidation by any person or
persons, that the University and/or its authorities shall not be liable for any accident or injury that may befall upon me while a student in the said institution.
I hereby affirm that all information written herein are complete and accurate. I am aware that any false information furnished in this enrollment form will
make me ineligible for admission or subject to dismissal in the University. I hereby give permission to the University to store and process my personal data in
adherence to the principles of transparency, legitimate purpose, and proportionality as required by RA 10173 or Data Privacy Act of 2012.
HARLEY DAVIDSON QUIMING SANTIAGO
Signature over Printed Name of Student
PARENT'S OR GUARDIAN'S GUARANTEE
I hereby conform to the pledge and waiver of my child in consideration to the admission requirements of the Central Luzon State University.
Maricel Q. Santiago
Signature over Printed Name of Parent/Guardian
(DO NOT WRITE BELOW THIS LINE)
Admitted to
Degree Program Bachelor of Science in Fisheries (BSF)
College COLLEGE OF FISHERIES
Department ATTACH HERE A RECENT 2”X2”
Admitted by: COLORED PHOTO WITH WHITE
BACKGROUND AND NAME TAG
For the College For the Office of Admissions (SURNAME, FIRST NAME, MIDDLE
INITIAL)
SIGNATURE OVER PRINTED NAME SIGNATURE OVER PRINTED NAME
Registration Adviser Record-in-Charge
Date Date
ACA.OAD.YYY.F.001 (Revision No. 2; March 9, 2020)
