TO BE FILLED OUT ONLY BY THE ADMISSION

OFFICER AND OR AUTHORIZED PERSONNEL TO APPLICATION ID

RECEIVE OR PROCESS APPLICATION URS-2022-021699
UNIVERSITY OF RIZAL SYSTEM
Province of Rizal Testing Center:
Website: http://www.urs.edu.ph
1 URS Angono 4 URS Cainta 7 URS Pililla 10 URS Taytay
2 URS Antipolo 5 URS Cardona 8 URS Rodriguez
URS APPLICATION FORM 3 URS Binangonan 6 URS Morong 9 URS Tanay
FOR COLLEGE ADMISSION
Documents/Requirements Submitted:
3 Photos 2x2 PEPT TOR Birth Certificate
1st Semester, SY 2022-2023
Form 137 Good Moral Testing Fee Passport
CEDP Certificate
TO THE STUDENT AND PARENTS: Honorable Dismissal

Carefully read the Instruction before filling out the application form.
L.R.N. 109311090201 Received By:
Print neatly all information required. Only accomplished application
form (URS College Admission Form) will be processed.

1 NAME OF STUDENT-APPLICANT. Print of type your full name in the following sequence. LAST NAME, FIRST NAME, MIDDLE NAME. Place one letter in each box. Leave one box between names.

LAST NAME H O L L M A N

FIRST NAME M H A R F R A N C I S Paste a recent 2''x2''

photograph (taken within
MIDDLE NAME D E L A C E R N A the last three months) in
this box
2 GENDER MALE FEMALE 3 RELIGION Roman Catholic

4 DATE OF BIRTH Month/ Day/ Year 05/17/2003 AGE 19 CIVIL STATUS SINGLE
Please print your full name
5 PLACE OF BIRTH CAVITE
at the back of the photo
5 CITIZENSHIP FILIPINO

FOREIGN (Specify) DUAL (Specify)

7 HIGHSCHOOL/SENIOR HIGHSCHOOL Where you completed/are completing Secondary Level Education EXPECTED DATE TRACK /
OF COMPLETION STRAND
SCHOOL NAME COLEGIO DE SAN CLEMENTE
May 2022 ACADEMIC /
ADDRESS 265A DOÑA AURORA ST, ANGONO, 1930 RIZAL
HUMSS

8 URS CAMPUS APPLIED FOR

URS CAMPUS INTENDED COURSE

FIRST CHOICE Angono Campus FIRST CHOICE BM ME

SECOND CHOICE AB ELS

SECOND CHOICE N/A FIRST CHOICE N/A

SECOND CHOICE N/A 2

GWA 90

9 ARE YOU A CHILD OF A URS FACULTY OR EMPLOYEE? YES NO

NAME OF PARENT EMPLOYED BY URS: OFFICIAL DESIGNATION:

COLLEGE/OFFICE EMPLOYED: TEL NO.:

10 PERMANENT ADDRESS 11 ARE YOU SELF-SUPPORTING?

B/L & NUMBER & STREET: 38 / 6 & 0 & ORCHIDS
YES NO
If YES, nature of work
SUBD./VILLAGE & BRGY.: GRAND VALLEY/ & BRGY. MAHABANG PARANG
Food Chain Crew Gasoline Boy/Girl
CITY TOWN/PROVINCE: ANGONO / RIZAL
Vendor Messenger
POSTAL CODE: 1930 TELEPHONE: 09362776574
Household Construction
EMAIL ADDRESS:: francis.hollman017@gmail.com
Others, please specify:
FACEBOOK ACCOUNT: https://www.facebook.com/franz.hollman17

12 SOCIO-ECONOMIC Furnish all the required information on each family lised. Write DECEASED after name of deceased family members. Under the Column "Highest
Educational Attainment" indicate the educational level which the household member actually completed.
HIGHEST
NAME CITIZENSHIP MARITAL PRESENT MONTHLY
EDUCATIONAL
STATUS ATTAINMENT OCCUPATION INCOME

FATHER ARJALE CARIGMA SAN NICOLAS FILIPINO MARRIED VOCATIONAL 2 YEARS SALESMAN 15000.00

MOTHER CARLA VERONICA YASMIN HOLL FILIPINO MARRIED COLLEGE GRADUATE CSA ADVISORY 2 30000.00

ANNIE DELA CERNA HOLLMAN FILIPINO MARRIED COLLEGE GRADUATE SOCIAL WORKER 5000.00
LEGAL GUARDIAN

This is to certify that all information given above is true and correct.

Signature over Printed Name of Applicant

THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED

URS-AA-SS-ADM-F-2017-01 Rev 01 Effective Date: Nov. 15, 2018