Republic of the Philippines

CENTRAL MINDANAO UNIVERSITY

University Town, Musuan, Bukidnon
OFFICE OF ADMISSIONS, SCHOLARSHIPS, AND PLACEMENT

APPLICATION FORM
Central Mindanao University College Admission Test (CMUCAT)

Testing Fee: ₱200.00 for 2nd Time Takers/transferees (Pay at the CMU Cashier’s Office) Application No.: CMUCAT-202412204Jnp3DBP
O.R. No: __________________________________________ Room No.: ________________________________

A. APPLICANT’S PROFILE
NAME: ROJAS KELSEY SOFIAAttach in this box LUTERO
(Family Name) (First Name) (Middle Name)
a recent 1x1 ID
BIRTH DATE 2006-05-18 picture of the AGE 2006-05-18
BIRTH PLACE CARMEN, CAGAYAN DE ORO applicant RELIGION CHRISTIAN
BIRTH RANK  eldest ☑2 nd
3  Others, specify __________________
rd
SEX ☐ MALE ☑FEMALE
CITIZENSHIP ☑ FILIPINO ☐ FOREIGN ☐ DUAL If Foreign/Dual Citizen, specify ________________
☐ YES
Member of Indigenous Peoples Group? If Yes, specify IPG ________________
☑ NO
A. EDUCATION LRN 126734120042
 Year of Graduation from Grade 6/Elementary School’s QUEZON CENTRAL ELEMENTARY
2019-04-05
School? Name SCHOOL
School’s QUEZON BUKIDNON COMPREHENSIVE
 Year of Graduation from Junior High School? 2023-07-12
Name NATIONAL HIGH SCHOOL
SENIOR HIGHSCHOOL NAME (Do Not
Abbreviate)
SHS Track/
Expected Year/ Year of SHS Graduation
Strand
ADDRESS (City/Town,
Region
Province)

For Transferees, HEI Name

HEI Address (City/Town, Province) Region
Degree Program Yr Level

B. COURSE/S YOU INTEND TO TAKE AT CMU C. SENIOR HIGH SCHOOL GRADE

CHOSEN COURSE/S ENGLISH 95
FIRST CHOICE BACHELOR OF SCIENCE IN BIOLOGICAL MATH 94
SECOND CHOICE BACHELOR OF SCIENCE IN PSYCHOLOGY SCIENCE 95
D. PERMANENT HOME ADDRESS
Number and Street BALANGAY 4-A POBLACION QUEZON BUKIDNON Barangay POBLACION
City/Municipality QUEZON Province BUKIDNON
Region REGION X (NORTHERN MINDANAO) Postal/Zip Code 8715
E. CONTACT INFORMATION
Telephone Number Cellphone Number 09268687145 E-mail Address kelseysofiarojas78@gmail.com
F. OTHER INFORMATION
 Are you a child of a CMU Faculty or Employee? ☐YES ☑NO  Are you a PWD?  YES  NO
If Yes, from what college/office If Yes, specify _________________________________________
Employment Status ☑ Permanent ☐ Temporary ☐ Others  Are you an  Orphan?  Self-supporting?
If Other(s), please specify  Are you a  Single Parent?  Senior Citizen?  Rebel Returnee?

G. SOCIO-ECONOMIC DATA Are you from a Single Parent household?  YES  NO Please fill out the appropriate information need.
Father’s Name Mother’s Maiden Name Legal Guardian (Other than parents)
Full name ROMEL S. ROJAS GLADES L. ROJAS
Citizenship FILIPINO FILIPINO
Highest Educational Attainment COLLEGE GRADUATE COLLEGE GRADUATE
Occupation BJMP POSTMASTER
Employer
Gross Household Income from regular sources ☐ below 5,000 ☐5,000-10,000 ☐10,001-25,000 ☐25,001-50,000 ☐50,001-100,000
☐100,001-150,000 ☐150,001-200,000 ☑200,001-250,000 ☐above 250,000
H. APPLICANT’S SIGNATURE
I hereby certify under the pain of perjury that all my statements above are true and correct to the best of my knowledge. I consent the Office of
Admissions, Scholarships, and Placement (OASP) may utilize my information in posting of the result and other legal purposes.

________________Kelsey Sofia L. Rojas ___________________ ______________________

Signature Over Printed Name Date
I. SCHOOL CERTIFICATION (To be filled by the School Personnel e.g. J. ACTION TAKEN (To be filled out by the CMUAT Board)
Principal, Guidance In-Charge, Class Adviser)
I hereby certify that Kelsey Sofia L. Rojas is a bona fide student of  APPROVED  DISAPPROVED  PENDING
QUEZON BUKIDNON COMPREHENSIVE NATIONAL HIGH SCHOOL for
the SY_________________. Remarks: ________________________________________________

______________________________________ _____________________________________
Name and Signature of School Representative CMUAT BOARD
Designation: _____________________________ Date: ________________ Date __________________________

Central Mindanao University College Admission Test (CMUCAT) PERMIT

Attach in this box a O.R. No. Application Number 202412204Jnp3DBP Date Filed 2024-12-20
recent 1x1 ID Name of Examinee Kelsey Sofia L. Rojas LRN 405035150112
picture of the Date of Test 2025-03-08 Time 8:00AM
applicant Place of Test QUEZON BUKIDNON COMPREHENSIVE Room No. 1
NATIONAL HIGH SCHOOL

Signature CMUAT Board

CMU-F-1-ASP-003 03 OCTOBER 2024 Rev. 2 Page 1 of 1