I.D. PICTURE Size must be less than 1MB.

Last Name Peñafiel

First Name Andre' Cesar
Middle Name Altoveros
Sex Male
Birthdate
(mm/dd/yyyy) 06/23/2002
Ex. 03/14/2007
Age 18
Birth Place (City) San Pedro
Birth Place (Province) Laguna
Birth Place (Region) Region IV-A
Civil Status Single
Citizenship Filipino
Religion Roman Catholic
Height (cm) 180 cm
Weight (kgs) 68
What social media platform do you often use?
Facebook
Home Address: Unit/House No./Blk &
Lot/Street/Subdivision Block 20 Lot 6, Mahogany Street Southview Homes 1

Barangay Pacita 2
Municipality/City San Pedro
Province Laguna
Region Region IV-A(CALABARZON)
Zip Code 4023
Mailing Address: Unit/House No./Blk &
Lot/Street/Subdivision Block 20 Lot 6, Mahogany Street Southview Homes 1

Barangay Pacita 2
Municipality/City San Pedro
Province Laguna
Region Region IV-A(CALABARZON)
Zip Code 4023
Contact Information: Home TelNo.
478-02-98

Mobile Phone No.

9495928303
Alternate Mobile Phone No. 9150596445
Gmail Address
penafielandrecesar3@gmail.com

Confirm gmail address penafielandrecesar3@gmail.com

Father's Full Name
(LastName, FirstName, MiddleName incl. Suffix)

Occupation
Name of Company
Mobile Number
Email Address
Mother's Full Name
(LastName, FirstName, MiddleName)

Occupation
Name of Company
Mobile Number
Email Address
Guardian's FullName
Ballano, Cesar Ballane
Occupation N/A
Name of Company N/A
Mobile Number 9175253255
Email Address csrblln2@gmailcom
Family is recipient of 4Ps
No
Number of Siblings (including self)
3

Order of birth among siblings Youngest

If answer is others, _______ (1st, 2nd, 3rd, 4th,
etc.)
EDUCATIONAL BACKGROUND:
Unique Learner Reference Number (LRN, 12 digit) 402593150158

Junior High School Name

Casa Del Niño Montessori and Science High School

JHS Complete Address

Fe Medalla Street, Barangay Pacita 2. San Pedro, Laguna
School Type:
Private, Public, Private Science, Public Science Private Science

Latest SY Attended 2019-2020

Recipient of academic excellence in Grade 10
N/A
Grade Average in Grade 10 85
Senior High School Name
Casa Del Niño Montessori and Science High School

SHS Complete Address

Fe Medalla Street, Barangay Pacita 2. San Pedro, Laguna
School Type:
Private, Public, Private Science, Public Science Private Science

Latest SY Attended 2019-2020

Track
Academic
Strand
STEM

Recepient of academic excellence in Grade 11?

N/A
List other awards/citations received (and year level
received) in High School for academic excellence:
N/A

list of other citation (non-academicList other

citations received (non-academics)/extra-curricular
activities in High School (and year level received)
N/A

Average in Grade 11, 1st sem 85

Average in Grade 11, 2nd sem 85
Name of SHS Principal Herbert M. San Pedro
Name of SHS Guidance Counselor Benito Casas
Name of SHS Coordinator Fernando Hofileña
SHS Contact No. 9491456436
Facebook Account/Page Casa Del Niño Schools System Inc.
College Name

Complete Address
School Type
Private or Public
Lastest SY Attended
Lastest Year Level Attended
Program (Course) Taken
List of awards/citation received for academic
excellence

Year received
Have you taken up kumon?
PREFERRED PROGRAM OF STUDY: BSMT OR
BSMarine Transportation
BSMarE
Who chose for you to take up maritime as a college
course Cousin

How many times have you taken the NTMAEE

I am in Grade 12, this is my first time

Year/s taken

How did you know about NTMA? NTMA Website

Facebook

Relatives

Depending on availability of slots, are you willing to

transfer Program of Study, i.e., from BSMT to
BSMarE? Yes

Are you going to avail of NTMA's Study-Now-Pay-

Later Program* No

Name family members/kin enrolled in/graduated

from NTMA? N/A

Class of NTMA Cadet/Alumnus

Relation
Do you have family members/kin who are
seafarers? Yes

Relation Cousin, Uncle

What do you know about NTMA?
State briefly why you are interested to pursue
maritime education/study in NTMA.
NTMA is a Maritime School that help future Cadets learn
about the course that they are taking.
My dream job is to become a Marine and I think that NTMA is
one of the best Marine School that can help me pursue my
dream.

Results of Ishihara Test

NA
(First Attempt)
Results of Ishihara Test
NA
(Second Attempt)
with PSA BC Uploaded NA
with TC of Grade 10 Report Card Uploaded NA
with TC of Grade 11 Report Card Uploaded NA
with TC of College Grades Uploaded

DISEASES/ILLNESSES:
1. Asthma, wheezing
(with breathing or exercise)*
No

If yes, state details:

Age of last asthma attack:
Age of last need for hospital treatment
17

Family member/blood relative with similar

condition? YES or NO No

2. Asthma (skin) No
If Yes, pls state details
3. Respiratory or other lung disease (e.g.,
Tuberculosis/PTB) No

If Yes, pls state details

4. Heart, blood or circulatory issues, such as
diabetes, high blood pressure, heart disease*
No

If Yes, pls state details

Family member/blood relative with similar
condition? YES or NO NO

5. Cerebral disease (e.g. stroke) or other brain

related conditions No

If Yes, pls state details

6. Epilepsy, seizures, fainting attacks or
convulsions
If Yes, pls state details
7. Recurring migraine headaches; blackout
episodes No

If Yes, pls state details

8. Frequent headaches; dizziness

If Yes, pls state details

9. Hearing loss or problems with balance
No

If Yes, pls state details

10.Serious eyesight issues No
If Yes, pls state details
11. Any eye deformity No
If Yes, pls state details
12. Bleeding, haematological or other blood
No
disorders
If Yes, pls state details
13. Ulcers or ulcer surgery No
If Yes, pls state details
14.Digestive or bowel disorder, or stomach
problems
No

If Yes, pls state details

15. Recurring joint or mobility problems/surgery
No
If Yes, pls state details
16. Scoliosis or other back related conditions
No
If Yes, pls state details
17. Physical disability No
If Yes, pls state details
18.Medically-certified pre-existing conditions that
may impact your learning, e.g., learning disabilities
No

If Yes, pls state details

19.Psychiatric or mental illness, including
depression No

If Yes, pls state details

20. Sexually Trasmitted Disease
No

If Yes, pls state details

21. High cholesterol* No
If Yes, pls state details
*Family member/blood relative with similar
condition: No

II. INJURIES:
22. Dislocation ("out of place bone"), Affected area

Others, specified answer

age during injury
cause of injury
details of cause of injury
Treatment -No Treatment
Treatment-Hilot
Treatment-Sling/Splint
Treatment-X Ray
Treatment-CT Scan
Treatment-MRI Scan
Treatment-Cast/Semento
Treatment-Surgery
Treatment-Hospital confinement
Others (Treatment), specified answer

23. Fracture ("broken bone") e.g. ACL Tear,

Affected Area
Left Arm

Others, specified answer

age during injury
cause of injury Sports Related
details of cause of injury
Basketball
24. Head Injury
age during injury
cause of injury
details of cause of injury
Treatment -No Treatment
Treatment-Hilot
Treatment-Sling/Splint
Treatment-X Ray
Treatment-CT Scan
Treatment-MRI Scan
Treatment-Cast/Semento Yes
Treatment-Surgery
Treatment-Hospital confinement
Others (Treatment), specified answer
25. Other bone, tendon, ligaments/cartilage-related
injury/disease (e.g. crooked arm)

If Yes, specified answer

Affected Part
Age during injury
Cause of Injury
Details of Cause of Injury
Treatment -No Treatment
Treatment-Hilot
Treatment-Sling/Splint
Treatment-X Ray
Treatment-CT Scan
Treatment-MRI Scan
Treatment-Cast/Semento
Treatment-Surgery
Treatment-Hospital confinement
Others (Treatment), specified answer
26. Do you smoke? No
If yes, how many cigarettes per day?
27. Do you drink liquior/alcoholic beverages?
Yes
If yes, how many bottles/can per dringking
Occasionally
session?
28. Do you have any allergies to medication?
No
If yes, please list:
29. Do you have any other allergy?
If yes, please list: No
30. Do you wear eyeglasses/contact lens?
No

If yes, please indicate grade of lens

31. DO you have a problem in hearing?

No

If Yes, please provide details

32. Do you have a tattoo? No

If yes, please indicate body area:

33. Do you have piercing? Yes

If yes, please indicate body part: Ear
34. Do you suffer from any phobias?
No

If Yes, please state.

35. Do you have a weight problem?
No

If Yes, please provide details

36. Have you been hospitalised in the last two
Yes
years
if yes, please state reason Dengue
37.Have you tested positive for Covid-19?
No

state answer if yes

38. Could you be a carrier of an infectious disease?
No
if yes, state answer
39. Do you have unusual skin conditions
No

if yes, state answer

40. Do you have an ongoing medical condition or
past medical problem not covered in this list?
No

If yes, state answer

Data Privacy Consent I hereby certify that all information supplied in th
 1. Please complete all items in Column B.
2. Refer to the Instructions/Guidelines in Column C.
ID size colored photo with white background (.jpg or .png extension)
3. Do not leave any field blank, put NA if not applicable or if y
4. Once completed, save and close. Re-name your file to you
(Ex. juandelacruz@gmail.com)
5. Only .xlsx format is accepted. Google Sheet/links and PDF
format as it may cause problem in our system.
6. Send the file to ntmaadmission@gmail.com via the Gmail a
IMPORTANT: Type your names based on your NSO/PSA-certified birth 7. Type in the Subject of the email your Gmail address. Ex. S
certificate (including Suffix, as applicable)

Only males are allowed to take the NTMAEE

Ex. "Region IV-A" for CALABARZON

Ex. "Single"
Ex. "Filipino" / "Filipino-American" if Dual Citizenship
Refer to https://psa.gov.ph/content/religious-affliation

Ex. "Facebook"
Ex. "Region IV-A (CALABARZON)"

Ex. "Region IV-A (CALABARZON)"

Include Area Code

Make sure that your mobile phone number is correct and can be
contacted
Other mobile number aside from declared mobile number in 31B
Make sure that your gmail account is correct and can receive mail as
this will be used in communicating with you

Indicate if deceased Ex. "Dela Cruz, Juan, Reyes (Deceased)"

Indicate if deceased Ex. "Dela Cruz, Anna, Reyes (Deceased)"

Fill out only if not living with and not under the care of a parent or
parents)

Indicate "Yes" or "No" if family is recipient of Pantawid Pamilyang

Pilipino Program (4Ps)

Ex. "Eldest" / "Youngest"/ "Only Child"

Order of birth if not eldest or youngest

No acronyms, include satellite or branch campus, if applicable, e.g.,
Pollux National High School-Turbine Branch. Be conscious with
spelling, e.g., St., Saint
Indicate Bldg./Street, Brgy., Municipality/City, Province, Region of
Junior High School

School type of Junior High School last enrolled in

Latest SY attended in Junior High School, Ex. SY2018-2019
Select from "With Highest Honor Award"/ "With High Honor Award"/
"With Honor Award"
Refers to General Average in Grade 10 as confirmed in Report Card
No acronyms, include satellite or branch campus, if applicable, e.g.,
Pollux National High School-Turbine Branch. Be conscious with
spelling, e.g., St., Saint
Indicate Bldg./Street, Brgy., Municipality/City, Province, Region of
Senior High School

School type of Senior High School currently enrolled in

Latest SY attended in Senior High School, Ex. SY2020-2021

Select from "Academic"/ "Sports"/ "Arts & Design"/ "Tech Voc" Tracks
If ACADEMIC (Select from): STEM/Pre-Bac Maritime
Specialization/HUMSS/ABM/GAS
If TECH VOC (Select from): TVL Maritime Specialization/Home
Econ./Industrial Arts/ICT/Agri-Fishery Arts
Select from "With Highest Honor Award"/ "With High Honor Award"/
"With Honor Award"

Ex. Position/s in student council, etc.

Refer to Report Card

Refer to Report Card
No acronyms, include satellite or branch campus, if applicable, e.g.,
Pollux College-Turbine Branch. Be conscious with spelling, e.g., St.,
Saint
Indicate Bldg./Street, Brgy., Municipality/City, Province, Region

Ex. SY 2020-2021
Ex. 1st Year, 2nd Year, Graduate
Spell out, no acronyms, e.g., BS Marine Engineering

Awards/Citation in college
Year level receipt of Awards/Citation in college
Cite if Math or Reading
Preferred Program of Study in NTMA: BSMarine Transportation or BS
Marine Engineering

Select from:
-I am in Grade 12, this is my first time
-I graduated from Grade 12 but not in College, this is my first time
-I am in College, this is not my first time

If not first time to take the NTMAEE, type year/s taken excluding this
year, e.g., "2019, 2018, 2017"
Choose Top three (3):
Visit of NTMA Team/ NTMA Alumni / NTMA Website/ NTMA
Facebook / NTMA Youtube Channel/ Internet Search /NTMA Cadet /
Friends /Parents /Relatives / Posters /Guidance Counselor or School
officials /Career Fair /Radio

Yes or No

Yes or No

If yes, cite relation, Ex., brother, cousin, uncle

Yes or No
If yes, cite relation, Ex., brother, father, cousin, uncle
State briefly

Put NA

Put NA
Put NA; Prepare PSA Birth Certificate for submission
Put NA; Prepare true copy (TC) of Grade 10 report card for submission
Put NA; Prepare true copy (TC) of Grade 11 report card for submission
Put NA; Prepare true copy (TC) of latest College grades for
submission, as applicable
For Rows 108 to 234, please be honest in indicating if you have
suffered from or you have been told that you had any of the
following conditions .
Answer either Yes or No. If Yes, please briefly state details.

If Yes to B108
If Yes to B108

If Yes to B108

If Yes, cite relation. Ex. Grandmother, father etc.

If Yes, cite relation. Ex. Grandmother, father etc.

If Yes, cite relation. Ex. Grandmother, father etc.
If Yes, specify affected area: Right Shoulder /Left Shoulder / Right
Knee/ Left Knee/ Right Hand/ Left Hand/ Right Elbow/ Left Elbow /
Right Hip/ Left Hip/ Others
If Others, specify

If Yes, indicate if "Sports related" or "Non-Sports Related"

Indicate Yes for treatments done, as applicable

If Others, specify
If Yes, specify affected area: Right Forearm / Left Forearm/ Right Leg /
Left Leg/ Right Ankle/ Left Ankle/ Right Hand or Wrist / Left Hand or
Wrist / Right Elbow/ Left Elbow/ Right Hip/ Left Hip/ Right Knee/ Left
Knee/ Others:

If Yes, indicate if "Sports related" or "Non-Sports Related"

Aside from details of cause of injury, also indicate treatments done, if
any

If Yes, indicate if "Sports related" or "Non-Sports Related"

Indicate Yes for treatments done, as applicable

If Others, specify
If Yes, indicate if "Sports related" or "Non-Sports Related"

Indicate Yes for treatments done, as applicable

If Others, specify
Please indicate agreement to the statement: "I hereby certify
that all information supplied in this form are accurate and I
authorize NTMA to verify all information provided herein. I am
aware that said information is confidential in nature and shall be
used only for purposes of my application. I also give my consent
freely and voluntarily to NTMA to use, share, and disclose the
personal data I provided on this form and in other electronic and
recorded forms for purposes related to my application only. I fully
understand that misrepresentation of information provided in this
form shall be grounds for non-admission and dismissal once
admitted."
 all items in Column B.
uctions/Guidelines in Column C.
field blank, put NA if not applicable or if you do not have answer.
save and close. Re-name your file to your provided Gmail address in 33B/34B of this Form.
@gmail.com)
is accepted. Google Sheet/links and PDF formats are not allowed. Do not change layout
use problem in our system.
tmaadmission@gmail.com via the Gmail address you provided in this Form.
ect of the email your Gmail address. Ex. Subject: juandelacruz@gmail.com