Ateneo De Zamboanga University

Ateneo de Zamboanga University

APPLICATION FOR COLLEGE ADMISSION

School Year 2018-2019

Fill out this form carefully and PRINT or TYPE all information requested. Only Application Forms correctly and completely filled out will be accepted. INCOMPLETE FORMS WILL NOT BE PROCESSED.

1. NAME ______

LastFirstMiddleNickname

2. HOME ADDRESS ______

House No.StreetBarangay

______

City/TownProvinceTel No. /Mobile No.

If you are from the province, please write the name of your relative living in ZamboangaCity and/or your Zamboanga City Address.

Name______Relation ______

Address______Telephone ______

Current Living Condition: Family Home DormitoryRelative’s House

Boarding House Other: Please specify ______

3. FATHER’S NAME______Living?Yes ( ) No ( )

If college graduate, from what school? ______Year ______Degree ______

If employed, name of company/employer? ______Position______

If self-employed, nature of work? ______Name of Company ______

MOTHER’S NAME______Living?Yes ( ) No ( )

If college graduate, from what school? ______Year ______Degree ______

If employed, name of company/employer? ______Position______

If self-employed, nature of work? ______Name of Company ______

Parents:Living TogetherSeparated Widowed

SPOUSE’S NAME (If married) ______Occupation ______

Family Structure:NuclearExtendedOther ______

Guardian (If any) ______Occupation ______

4. DATE OF APPLICANT’S BIRTH ______Age ______Place of Birth ______

5. CITIZENSHIP ______Religion ______Sex ______Civil Status ______

Are you an International student? No Yes, from (place of origin) ______

6. ETHNIC AFFILIATION: ( ) Visayan ( ) Samal ( ) Zamboangueño ( ) Yakan ( ) Tausug ( ) Others: ______

7. LANGUAGES / DIALECTS SPOKEN: ______

8. PRESENT SENIOR HIGH SCHOOL ______Section (Name, Letter or Number) ______

9. BROTHERS’ AND SISTERS’ EDUCATIONAL ATTAINMENT. Where studying or graduated – eldest to youngest.

NameName of High SchoolName of CollegeYear/Course

a. ______

b. ______

c. ______

d. ______

e. ______

If married, list down the names and ages of your children – eldest to youngest.

NameAgeGrade or Year LevelSchool

a. ______

b. ______

10. SCHOOL ATTENDED: Beginning from the lowest grade, list in order all schools attended. This must be a complete listing of

every school in which you have enrolled.

ElementaryAddress

______Grade _____ to Grade _____ 20___ to 20___

Junior High SchoolAddress

______Grade _____ to Grade _____ 20___ to 20___

Senior High SchoolAddress

______Grade _____ to Grade _____ 20___ to 20___

11. Name of the PRINCIPAL or DIRECTOR and GUIDANCE COUNSELOR of your present senior high school:

Principal ______Guidance Counselor ______

12. Did you ever repeat a year in high school? If so, which grade? ______

13. Were you ever dismissed, suspended, or placed on probation by your high school? ______

Dates, Offenses, Penalties ______

14. PHYSICAL and / or LEARNING DISABILITIES: ______

15. HEALTH QUESTIONNAIRE: Please answer the following questions: Height ______Weight ______

Do you / Yes / No / Have you / Yes / No
a. Smoke? / f. Been hospitalized for any reason?
If yes, please specify for what reason and current status.
b. Drink alcoholic drinks? / g. Undergone surgery?
c. Have problems falling asleep? / h. Been diagnosed with any chronic medical conditions?
d. Have memory lapses? / i. Undergone psychiatric assessment or treatment?
If yes, please specify diagnosis, management and current status.
e. Take any medications?
If yes, please specify the medication and for what condition.

18. Person to contact in case of emergency:

Name: ______Relationship: ______

Complete Address: ______

Contact Numbers: Residence: ______Mobile Phone: ______

Place of Employment: ______

19. PROGRAMS OF STUDY. Check ( √ ) the program you wish to follow. Indicate a second choice by placing the number 2 before

the name of the program. Also, make a 3rd choice by placing the number 3 before the name of the program.

_____ AB Economics_____ Bachelor of Elementary Education

_____ AB English_____ Bachelor of Secondary Education

_____ AB Interdisciplinary Studies_____BS Information Technology

_____ AB International Studies_____ BS Internal Auditing

_____ AB Philosophy_____BS Legal Management

_____BA Communication_____ BS Management Accounting

_____BS Accountancy_____ BS Mathematical Sciences

_____ BS Accounting Information System_____ BS Mathematics

_____BS Biology_____ BS New Media and Computer Animation

_____BS Business Administration_____ BS Nursing

_____BS Computer Engineering_____ BS Office Administration

_____BS Computer Science_____BS Psychology

_____BS Electronics and Communications Engineering_____BS Statistics

20. EDUCATION AND CAREER PLANS.

Did (do) your father or mother, or other members in your family help you in making your educational plans? ______If yes, who specifically? ______. In making your educational plans did you make them first and then discuss with your parents? _____ . Did your parents made them first and discuss them with you? _____. With whom else have you discussed your plans? ______.

Why have you decided to go to college? (Check as many as you think are true)

To get a liberal educationTo prepare for a vocationFor a prestige of a college degree

To get a jobTo be with old school friendsTo make friends and helpful connections

For social enjoyment (College life) I don’t know whyTo please my parents/relatives

Other. Please specify ______

Financial Support in College:

Entirely supported by familyScholarship: Type ______Student Assistant

Full Time/ Part time Worker Outside ADZUOther: ______

Principal reason for selecting Ateneo de Zamboanga University: ______

______

Occupational Preferences: (Regardless of present course choice)

1. ______Reason ______

2. ______Reason ______

I hereby certify that all the information written in this application is complete and accurate. I agree if accepted as a student that my admission, matriculation, and graduation are subject to the rules and regulations of the Ateneo de Zamboanga University.

Student’s Signature over Printed Name ______Date: ______