F-ADMS-2751 REPUBLIC OF THE PHILIPPINES

Rev. 2, August 2020 CAGAYAN STATE UNIVERSITY

College Admission Test Registration Form Registration Number

Instructions: Fill in all the required information. DO NOT leave an item blank. If item is not applicable, indicate “N/A”.
PERSONAL INFORMATION
NAME:
Last Name First Name Middle Name Suffix (ex.: Jr., Sr., III)
BIRTHDATE: (mm/dd/yy) ________________ SEX: ______ CIVIL STATUS: ________ Citizenship: _________ RELIGION: _______________
HOME ADDRESS:
Street No., Barangay Municipality Province
(If Boarding) ADDRESS:
Street No., Barangay Municipality Province

FATHER’S NAME: ______________________________ MOTHER’S NAME: ______________________________

EMAIL ADDRESS (make sure email address is active): ___________________________ YOUR CONTACT NUMBER: ___________________
CONTACT NUMBER OF PARENTS/GUARDIAN: ______________________________

EDUCATIONAL BACKGROUND
SCHOOL CURRENTLY ENROLLED IN: ______________________________________________________
(If not enrolled) SCHOOL LAST ATTENDED: ______________________________________________________________
SCHOOL ADDRESS: ________________________________________________________________
LEARNING REFERENCE NUMBER (LRN): ______________________________________________
K-12 STRAND: ___________________
TYPE OF SCHOOL: (shade your answer)
o Private/Non-Sectarian (if non-religious school) o Technical-Vocational High School
o Private/Sectarian (if religious school) o Agri-Fisheries High School
o National High School o Agricultural-Technical-Vocational High School
SOCIO-ECONOMIC PROFILE: (Put a check mark on the alternative that corresponds your answer)
FAMILY INCOME:
___₱0 – ₱11,914.50 ___₱35,744 – ₱47,658.50
___₱11,915 – ₱23,829.50 ___₱47,658.50 above
___₱23,830 – ₱35,743.50
OUR FAMILY RESIDES IN:
___Our own house ___An apartment
___A rented house ___A house owned by relatives (nakikitira)
WHAT IS YOUR FATHER’S OCCUPATION?
___None ___Government Employee, Please Specify: ________________
___Farmer ___Private Employee, please specify: ____________________
___Fisherman ___ OFW, Please Specify: ______________________________
___Laborer ___If Deceased
___Self-employed, Please Specify: ___________________
WHAT IS YOUR MOTHER’S OCCUPATION?
___Housewife ___Private employee, please specify: _____________________
___Manual Laborer, please specify: __________________ ___OFW, please specify: _______________________________
___Self-Employed, please specify: ________________ ___If Deceased
___Government employee, please specify: ________________
WHO AMONG THE OTHER FAMILY MEMBER IS/ARE EARNING? __________________
HOW MANY MEMBERS ARE THERE IN YOUR HOUSEHOLD? _____________________
HOW MANY SIBLINGS (BROTHERS AND SISTERS) DO YOU HAVE? ___________________
HOW MUCH IS YOUR DAILY ALLOWANCE?
___Php50 pesos per day or below: Please Specify ________ ___Php80 pesos per day
___Php60 pesos per day ___Php90 pesos per day to 100 per day: Please specify: _______
___Php70 pesos per day ___More than Php100 per day: Please specify: ______________
ARE YOU A MEMBER OF AN INDIGENOUS CULTURAL COMMUNITY RECOGNIZED BY THE NATIONAL COMMISSION ON INDIGENOUS
PEOPLES?
___If YES, please specify: ________________________ ___NO
WHAT LANGUAGE DO YOU SPEAK AT HOME? (Please choose 1 you often use)
___Ibanag ___Itawes ___Ilocano ___Tagalog ___English OTHERS: (Please specify): ___________________

Continue at the back page

 COURSE PREFERENCE: Please indicate the 2 courses of your choice by writing 1 as your FIRST CHOICE; 2 as your SECOND CHOICE.
ANDREWS CAMPUS
___Bachelor in Early Childhood Education ___Bachelor of Science in Accounting Information System
___Bachelor of Culture and Arts Education Major in Music ___Bachelor of Science in Business Administration (choose 1 major)
___Bachelor of Elementary Education ___Financial Management ___Marketing Management
___Bachelor of Secondary Education (choose 1 major) ___Bachelor of Science in Entrepreneurship
___English ___Filipino___ Mathematics ___Science ___Social Studies ___Bachelor of Science in Hospitality Management
___Bachelor of Technical-Vocational Teacher Education (choose 1 major) ___Bachelor of Science in Legal Management
___Electronics Technology ___Food Service Management ___Bachelor of Science in Medical Laboratory Science
___Bachelor of Technology and Livelihood Education (choose 1 major) ___Bachelor of Science in Public Health
___ Agri-Fishery Arts ___Home Economics ___Bachelor of Science in Respiratory Therapy
___Bachelor of Science in Accountancy
APARRI CAMPUS
___Bachelor of Elementary Education ___Bachelor of Science in Hospitality Management
___Bachelor of Secondary Education (choose 1 major) ___Bachelor of Science in Information Technology
___English ___Mathematics ___Sciences ___Bachelor of Science in Industrial Technology (choose 1 major)
___Bachelor of Science in Accounting Information System __Automotive Technology __Electrical Technology __Electronics Technology
___Bachelor of Science in Criminology
___Bachelor of Science in Fisheries and Aquatic Sciences
CARIG CAMPUS
___Bachelor of Arts in Communication ___Bachelor of Science in Chemistry
___Bachelor of Arts in Economics ___Bachelor of Science in Computer Science
___Bachelor of Arts in English Language Studies ___Bachelor of Science in Environmental Science
___Bachelor of Arts in Political Science ___Bachelor of Science in Industrial and Commercial Communication
___Bachelor of Library and Information Science ___Bachelor of Science in Industrial Technology (choose 1 major)
___Bachelor of Multimedia Arts ___Architectural Drafting Technology ___Automotive Technology ___Electrical Technology
___Bachelor of Physical Education ___Electronics Technology ___Fashion & Apparel Technology ___Food Technology
___Bachelor of Public Administration ___Garment Technology ___Heating Ventilation & Air Conditioning Technology
___Mechanical Technology ___Refrigeration and Air-Conditioning
___Bachelor of Science in Agriculture and Bio System Engineering
___Bachelor of Science in Information System
___Bachelor of Science in Architecture
___Bachelor of Science in Information Technology
___Bachelor of Science in Chemical Engineering
___Bachelor of Science in Mathematics
___Bachelor of Science in Civil Engineering
___Bachelor of Science in Physics
___Bachelor of Science in Computer Engineering
___Bachelor of Science in Psychology
___Bachelor of Science in Electrical Engineering
___Bachelor of Science in Social Work
___Bachelor of Science in Electronics Engineering
___Bachelor in Human Services
___Bachelor of Science in Exercise and Sports Sciences (choose 1 major)
___Doctor of Veterinary Medicine
___Fitness & Sport Coaching ___Fitness & Sports Management
___Certificate in Industrial Technology
___Bachelor of Science in Biology
GONZAGA CAMPUS
___Bachelor of Elementary Education ___Bachelor of Science in Agriculture (choose 1 major)
___Bachelor of Secondary Education (choose 1 major) ___Animal Science ___Crop Science
___English ___Filipino ___Bachelor of Science in Hospitality Management
___Bachelor of Science in Accounting Information System ___Bachelor of Science in Information Technology
___Bachelor of Science in Criminology ___Diploma in Agricultural Technology
LAL-LO CAMPUS
___Bachelor of Elementary Education ___Bachelor of Science in Agriculture (choose 1 major)
___Bachelor of Secondary Education (choose 1 major) ___Animal Science ___Crop Science
___English ___Filipino ___Mathematics ___Science ___Social Studies ___ Bachelor of Science in Information Technology
___Bachelor of Science in Hospitality Management ___Diploma in Agricultural Technology
LASAM CAMPUS
___Bachelor of Elementary Education – Generalist Curriculum ___Diploma in Industrial Technology (choose 1 major)
___Bachelor of Secondary Education – Major in English ___Automotive ___Electronics ___Food Technology ___Mechanical Technology
___Bachelor of Science in Information Technology
_ ___Bachelor of Science in Industrial Technology (choose 1 major)
__Automotive Technology __Electronics Technology __Food Technology __Mechanical Technology
PIAT CAMPUS
___Bachelor of Elementary Education ___Bachelor of Science in Criminology
___Bachelor of Secondary Education (choose 1 major) ___Bachelor of Science in Agriculture (choose 1 major)
__English __Mathematics __Social Studies ___Animal Science ___Crop Science
___Bachelor of Technology and Livelihood Education (choose 1 major) ___Bachelor of Science in Information Technology
___Agri-Fishery Arts ___Home Economics ___Diploma in Agricultural Technology
SANCHEZ MIRA CAMPUS
___Bachelor of Elementary Education- Generalist Curriculum ___Bachelor of Science in Information Technology
___Bachelor of Secondary Education (choose 1 major) ___Bachelor of Science in Industrial Technology (choose 1 major)
___English ___General Science ___Mathematics ___Filipino ___Automotive Technology ___Architectural drafting ___Electrical Technology
___Bachelor of Science in Accounting Information System ___Electronics Technology
___Bachelor of Science in Agricultural and Bio System Engineering ___Certificate in Industrial Technology (choose 1 major)
___Bachelor of Science in Agriculture (choose 1 major) ___Architectural Drafting ___Automotive Technology ___Electrical Technology
___Animal Science ___Crop Science ___Electronics Technology
___Bachelor of Science in Criminology ___Diploma in Agricultural Technology
_ ___Bachelor of Science in Hospitality Management
CSU-IRAGA EXTENSION
___Bachelor of Elementary Education ___Bachelor of Science in Criminology
___Bachelor of Science in Agriculture (choose 1 major) ___Bachelor of Science in Fisheries
___Animal Science ___Crop Science ___Bachelor of Science in Information Technology

Applicant’s signature over printed name Signature over printed name of officer-in-charge

1X1 ID
Applicant’s signature over printed name Signature over printed name of officer-in-charge REGISTRATION PICTURE
NUMBER
Date of registration: ____________ Place of registration: _____________________