Reference No.: OMSC-Form-ADC-01-D Effectivity Date: January 07, 2022 Revision No.
04
Date of Application:_______________
Jan 24, 2024
Republic of the Philippines
OCCIDENTAL MINDORO STATE COLLEGE
Labangan, San Jose, Occidental Mindoro
Website: https://www.omsc.edu.ph/ Email address: [email protected]
2x2 colored ID picture
Tele/Fax: (043) 457-0889
with white background
Admission Center
ADMISSION FORM FOR FIRST YEAR COLLEGE STUDENTS
STUDENT'S PERSONAL INFORMATION LRN: 110087100005
(Found on the SHS Report Card)
Last Name: A N D A L E S Gender: Male Female
First Name: J O Y M A E Gender Identity: Man Woman
Middle Name: G A A N Civil Status: Single Separated
Married Widowed
Extension Name: (Jr./Sr./III, etc..; if not any, write None.)
Cohabitation (Live-in)
Ethnic Group (Specify. if not any, write None.) : ____________________
Tagalog Age: ___________
19 Religion: ______________________
Roman Catholic
Date of Birth (E.g. January 01, 2001) : ____________________
March 26, 2004 Place of Birth: ______________________________________
Kinarasyawan,malpalon, Calintaan , Occidental Mindoro
Complete Mailing Address: _____________________________________
SITIO KINARASYAWAN , MALPALON, CALINTAANContact Number/s: _____________________
09066761636
Blood Type: _______________
A+ Email Address: ___________________________________________________________
[email protected]Type of Disability (Specify. if not any, write None.) : _________________________
None Opt: *Deaf or Hard of Hearing *Intellectual Disability
*Learning Disability *Mental Disability *Visual Disability *Orthopedic Disability *Physical Disability *Psychosocial
*Speech and Language Impairment Others (Specify): ________________________
EDUCATIONAL INFORMATION
GOVERMENT
PRIVATE
NAME OF SCHOOL AND ADDRESS YEAR HONOR/AWARD
LEVEL
(Write in full; do not abbreviate.) GRADUATED (If you did not receive any. write None.)
Name:
SENIOR HIGH Address:
Strand:
General Weighted Average (GWA):______________________________ Course Intended to Enroll: 1st Priority:______________________________
LB BSSOW
OMSC Campus:_____________________________________________________________________
Labangan 2nd Priority:______________________________
LB BSARCH
FAMILY BACKGROUND (Write NA if Not Applicable; None if not any.)
EXTENSION MIDDLE NAME
EDUCATIONAL
LAST NAME FIRST NAME NAME (Write in full; do not abbreviate.)
(e.g. Jr., II) (Write None if No Middle Name) ATTAINMENT
Father's Name ANDALES MACARIO DELOS SANTOS ELEMENTARY
Occupation FARMERS
Mother's Name
ANDALES JOSEPHINE GAAN ELEMENTARY
(Maiden Name)
Occupation HOUSE WIFE
Guardian's Name ANDALES MELBERT GAAN BACHELORS DEGREE
Occupation
Spouse's Name
Occupation
Annual Family Income: Below 50,000 Php 50,000 Php and above 100,000 Php and above 150,000 Php and above
CONTACT INFORMATION IN CASE OF EMERGENCY
Name:_______________________________________________________
ANDALES, MELBERT GAAN Address: _______________________________________________________
MALPALON SITIO KINARASYAWAN CALINTAAN OCCIDENTAL MINDORO
Contact Number/s:____________________________________________
09757146393 Relationship: ____________________________________________________
BROTHER
---------------------------------------------------------------------------------------------------------------------------------------- To be filled-out by the Admission Coordinator-----------
I hereby certify that all the information given above are correct, and REQUIREMENTS SUBMITTED:
I grant my concern to and recognize the authority of Occidental Original & 2 Photocopies of Report Card
Mindoro State College to process my personal information, in Photocopies of PSA-issued Birth Certificate
connection with my application to shift/transfer/be admitted as a 2x2 ID Picture with a name tag and white background
student of OMSC. Original & 2 Photocopies of Certificate of Good Moral (with dry seal)
Student's Signature Original & 2 Photocopies of Honorable Dismissal
Transcript of Records
________________________________ CHEST X-RAY
Assessed by : ____________________
ANDALES, JOY MAE GAAN
Date processed : ____________________
January 24, 2024
