ADMISSION FORM

APPLICATION NUMBER Documents submitted:

□ Resume w/ Two (2) 2” x 2” ID pictures
_ _
□ School Records
 For Senior High Graduates
o Photo copy of Report Card
Reminders: o Photo copy of Diploma
 Please TYPE or PRINT in BLOCK LETTERS all information  For College Students
o Photo copy of Transcript of Records (TOR)
required legibly and completely. o Photo copy of Diploma
 Write “N/A” for fields that are not applicable. □ Barangay Certificate
 Use the name that appears in your previous school records.
□ Social Case Study Report (from the local government unit)
 Attach admission requirements.
□ Photo copy of Persons with Disability (PWD) ID
□ Photo copy of Marriage Certificate (for married female students)
PERSONAL INFORMATION: Please TYPE or PRINT in BLOCK LETTERS. THIS FORM IS TO BE ACCOMPLISHED BY NEW STUDENTS ONLY.

Ancheta Arnold Gulpe Arnie

Family Name Full Given Name Suffix Middle Name Nickname
(Jr., Sr., II)
9005 Trinidad St. cor. CF Gonzales St. Brgy. Pulo, San Rafael Bulacan Landmark: Pulo Elementary School
Mailing Address :
House or Building Number Street Barangay or Subdivision Town District
9005 Trinidad
ZipSt. cor. CF Gonzales St. Brgy. Pulo, San Rafael Bulacan
Code
Permanent Address :
House or Building Number Street Barangay or Subdivision Town District

Male Single Place of Birth : Manila Personal E-mail: [email protected]

Married Date of Birth : May 20, 1975 Landline No. : N/A
Female Widow/er Nationality : Filipino Mobile No. : 09957315363 Globe
Separated Religion : Roman Catholic
Father’s Name: Contact No. Mother’s Maiden Name: Contact No.

EDUCATIONAL INFORMATION:
Name and Address of School Date Graduated Degree/Course Taken
Senior High School St. Francis Catholic School, Sta. Ana Manila 1988 - 1992
Vocational School (Certificate Program)
College School Access Computer & Technical College, Recto Manila 1996 - 1998 Computer Technology

WORK/BUSINESS INFORMATION: From the most recent employment to the oldest.

Job
Position Class* Company Name and Address Inclusive Dates Industry Classification
Computer Technician Service Dept. Allied Computer System, Lamayan St. Sta. Ana Manila 1998 - 2006 Information Technology

*Job classification within the company (i.e. Rank and File, Supervisory, Section Manager, Department Manager, Top Management)

VERIFICATION AND AUTHORIZATION:

I have carefully read the contents of this application form. I certify that the information given herein is complete and accurate. Falsification, misrepresentation, or
withholding of information requested in this form will automatically nullify my application and/or or may be used as a ground for my dismissal from De La Salle-College of Saint
Benilde.
I understand that I should also complete the documentation requirement prior the start of the program I am enrolled in. Failure to do so will invalidate my enrolment
and will disqualify me from receiving the certificate on the program.

Arnold G. Ancheta February 02, 2021

Printed Name & Signature of Applicant Date
Application processed by:
Printed Name & Signature of Program Associate Date
ORIENTATION: Attended Not Attended

Type of Disability (Please check that applies to you): How did you come to know about the SBJHI programs?
□ Hearing Disability □ Print Ads □ Benilde Alumni
□ Intellectual Disability □ Referral □ Alumni of other La Salle Schools
□ Learning Disability □ SBJHI FB Page □ Friends
□ Physical Disability □ Flyers □ Relatives
□ Psychosocial and Behavioral Disability □ Exhibits or Conferences □ Exhibit/Trade Shows
□ Speech Impairment □ Facebook __________________
□ Visual Disability □ Twitter __________________

SBJHI Admission Form 01 V6.21 31 May 2018