Don Mariano Marcos Memorial State University

La Union, Philippines
RECENT 2x2 picture with
FREE HIGHER EDUCATION APPLICATION FORM name tag in white
FIRST SEMESTER, SY 2023-2024 background

CAMPUS:  NLUC  MLUC  SLUC OU

Date of Application:_____________________

Directions: Fill-out by putting a check mark (/) on the appropriate box or by writing the needed
information. Please write legibly.

I. STUDENT INFORMATION
Name __________________________________________________ ID Number: _______________
Complete Home Address: _________________________________________________________________
Sex:  Male  Female Civil Status:  Single Married
Contact Number _________________________ E-mail address _______________________________
Course: ___________________________________________ Year Level: _____________________

Type of Student:  New  Continuing  Returning Student

*if NEW, indicate name of school last attended: ________________________________________________
School year last attended: _________________

Are you a recipient of any scholarship/grant? Yes No

If yes, write the complete name of the scholarship/ grant and amount of stipend received per semester
___________________________________________________________________________________

II. FAMILY INFORMATION

ESTIMATED FAMILY
NAME OF PARENTS OCCUPATION
INCOME
Father
Mother
Total Monthly Family Income

I hereby certify as to the correctness of the information provided.

__________________________________ ______________________________________
Signature of Applicant over printed name Signature of Parent/Guardian over printed name

Evaluated by:
REMARKS:
MELODY PACIS-TUMANAN  Approved
In-charge, Scholarship and Financial Assistance  Disapproved/ Ineligible
 Second Courser
 Overstaying
Noted by:  With other scholarship (DOH and DA-ATI)

JO ANN P. RULLA Date Evaluated: _______________________________

Head, Student Affairs and Services

DMMMSU-SAR-F052
Rev. No. 02 (04.07.2022)