AGUSAN DEL SUR STATE COLLEGE OF AGRICULTURE AND TECHNOLOGY

Bunawan, Agusan del Sur

website: http://asscat.edu.ph
email address: asscatjvg@gmail.com

19084895

PRE-ADMISSION APPLICATION FORM

Guidance Office Copy
Please write your answers in BOLD LETTERS in the space provided
below each item.
1. SURNAME 2. FIRST NAME 3. MIDDLE NAME
RULOMA MIKI ANTON Glue your recent
4. DATE OF BIRTH (mm-dd-yyyy) 5. AGE 6. SEX PASSPORT SIZE ID picture
03-16-2001 19 FEMALE here
7. CITIZENSHIP 8. RELIGION
FILIPINO ROMAN CATHOLIC
9. NAME & ADDRESS OF LAST SCHOOL ATTENDED (Please write the complete name of the school)
AGUSAN DEL SUR NATIONAL HIGH SCHOOL BRGY. 5, SAN FRANCISCO, AGUSAN DEL SUR
10. PERMANENT ADDRESS
P-3, BRGY. TAMBIS, BAROBO, SURIGAO DEL SUR
11. E-MAIL ADDRESS 12. MOBILE NUMBER
kayeanton16@gmail.com 09486702166
13. FATHER’s COMPLETE NAME 14. FATHER’s OCCUPATION
PEDRO C. RULOMA RETIRED PNP
15. MOTHER’s COMPLETE NAME 16. MOTHER’s OCCUPATION
JOSEPHINE A. RULOMA HOUSE WIFE
17. Priority Course want to enroll: Board Course: Non-board Course:
(1) BS CIVIL (1)_________________________
ENGINEERING_____
(2)__________________________
(2)_____________
(3)
(3)
18. PLEASE CAREFULLY READ THE STATEMENT BELOW BEFORE PROCEEDING TO ITEMS 19 AND 20.
I certify that I have read and understood all the instructions and questions set forth in this application form; and all
answers in this form are true and correct. I understood that any false information and/or statement may result in the
refusal of admission into the College.
19. APPLICANT’s SIGNATURE 20. DATE OF SUBMISSION 21. RECEIVED BY (To be filled-up by the
JUNE 15, 2020 Staff):