FORM
20
Ateneo de Davao University ADDU (04-2014)
Previous Edition Obsolete
Office of Admission and Aid
Application for Admission to Undergraduate Studies
Recent
Instructions:
1x1
1. Fill out this form carefully and print (in BLOCK letters) or type all information requested.
Photo of
2. Submit all requirements along with this form.
Applicant
3. Only application forms properly accomplished and submitted with the complete requirements will be processed.
4. Only application forms with original signatures of the applicant and the [Link] will be processed
Name as it appears on the Birth Certificate Course(s) Applied for in order of preference
Last Name Suffix 1
First Name 2
Middle Name 3
Basic Personal Information
Birthdate Civil Satus
Birthplace Citizenship
Gender Religion
Contact Information
PERMANENT ADDRESS CITY ADDRESS Same as Permanent Boarding With Relative
House No. House No.
Street Street
Subdivision/Sitio Subdivision/Sitio
Barangay Barangay
City/Municipality City/Municipality
Province/Country Province/Country
Telephone No(s). Zip Code Telephone No(s). Zip Code
Mobile No. Email Address
Family Background
Position in the Family(e.g. eldest) No. of Brothers No. of Sisters
PARENTS Name Occupation Living Contact No.
Father
Mother
Parent's Marital Status
Name of Spouse (if married)
In Case of Emergency (if boarding or living with relative, indicate name of landlady of guardian as person to contact)
Person to Contact Relationship
Telephone No. Mobile No.
It is the policy of the Ateneo de Davao University, in accordance with the Manual of Regulations for Private Higher Education 2008 (MORPHE) and the Education Act
of 1982, to withhold disclosure of personally identifiable information from educational records unless the student has consented to disclosure or the law allows such
disclosure.
By checking the boxes below, you give consent to disclose your education records to your parents, legal guardians, and other designed agencies or grant institution
you specify. The purpose of the consent is to allow the University to release the educational records, awards and student information. This consent will remain on
your records. Such information includes degrees, grades, course schedules, disciplinary records, awards and student information. This consent wil remain on your
records and allow the University to release information to your parents, legal guardians, and agencies specified, even when you are no longer listed as a dependent
on your parent's income tax return, or you have graduated and left the University, unless you revoke this permission by notifying the Registrar's Office in writing
your intent to do so. Please check the boxes below to indicate your consent for the University to disclose educational records and information to your parents, legal
guardians, and specific agency:
Parents as listed above Legal Guardians Name: ___________________________ Agency: _______________________________
PLEASE DO NOT WRITE BELOW THIS LINE
Application Fee Paid (DBC Admissions) OR No. ____________________ Amount: ___________________ Date: ___________________ Cashier: __________________
Regular Conditional Remarks
Code Section
FORM 20 (ADDU 04-2014)
Page 1
FORM 20
ADDU (04-2014)
Previous Edition Obsolete
EDUCATIONAL BACKGROUND
Name of School Address Years Attended
Primary
Grade School
High School
Additional Information for High School
Principal's Name Guidance Counselor's Name
Contact Numbers
Awards Received in High School -- Academic Honors, Special Awards, if any. (please indicate the awards received, the awarding institution and date)
HEALTH / MEDICAL PROFILE
Blood Group Rh
Family/Personal
Physician's Contact Information
Physician's Name
Presently taking
If yes, please indicate:
medication?
List any health problems for which you are currently receiving treatment:
Do you allow the University Integrated Health Services to confer with your physician regarding your condition?
PSYCHOLOGICAL PROFILE
Are you currently in therapy, rehabilitaion, or clinical counseling elsewhere?
If yes, with whom: Contact Information
Briefly describe your reason for seeking help:
PERSONAL ESSAY
The 500-word essay should be one page long, handwritten on a long bond paper (page 3 of this form). Topics selected at random will be given to the applicant as soon as the application form is filled
out. The essay must be written by the applicant unassisted. No parent or guardian is allowed inside the essay-writing and interview areas.
Preference of parent / guardian in receiving Grade Report Card (select one)
Please send thru email Please send thru postal mail
Indicate Email address below Indicate Parent/Guardian's Billing Address below
APPLICANT'S UNDERTAKING
I hereby certify that all information written in this application is complete and accurate. If accepted as a student, I agree that my admission, registration, and graduation are subject to the rules and
regulations of the Ateneo de Davao University.
APPLICANT'S SIGNATURE PARENT'S / GUARDIAN'S NAME AND SIGNATURE
DATE SIGNED
IMPORTANT: Credentials filed in support of this application become the property of the Ateneo de Davao University and will not be returned to the applicant. Misrepresentation of information
requested in this application will be sufficient reason for refusal of admission and exclusion.
FORM 20 [ADDU 04-2014]
Page 2
FORM 20
ADDU (04-2014)
Previous Edition Obsolete
LEGAL NAME:
(Name in Birth Certificate) Last Name First Name Middle Name
PERSONAL ESSAY
ESSAY CODE: _____________ START: ______________ END: ________________
CLASSIFIED RECORDS
FORM 20 [ADDU 03-2015]
Page 3
FORM 20
ADDU (04-2014)
Previous Edition Obsolete
LEGAL NAME:
(Name in Birth Certificate) Last Name First Name Middle Name
FOR INTERVIEWER ONLY
Date:
Communication Skills
[ ] MD ART
[ ] HG ART
If on probation/waitlisted, number of units allowed to be enrolled:___
Composure
[ ] MD CFD
[ ] CFD
Courses to be excluded in the Registration Form this coming semester:
[ ] VY CFD
Career Path
[ ] UC CRSE Initial Observation:
[ ] CERT CRSE
Influence Factor
[ ] PRTS
[ ] PERS
[ ] INT
[ ] OT ________
Initial Recommendation
[ ] NT RCMD ADM (Send Applicant to Admissions Committee)
[ ] RCMD ADM
[ ] RCMD ADM PROB
[ ] RCMD ADM FN PROB
Behavioral Observation
[ ] RCMD GUI
[ ] RCMD MON
[ ] RCMD BV PROB Name of Interviewer / Evaluator:
Recommendations
[ ] RCMD ADM
[ ] RCMD ADM W RSVT Program / Department / School
[ ] NT RCMD ADM
IMPORTANT: After this page is filled out, the formmust not be shown to the applicant nor to any party unless authorized by the Department Chair or any of his/her representative or university [Link]
informationon this page is classified/confidential.
Notes: (Please put date evry time new entry is added)
CLASSIFIED RECORDS
FORM 20 [ADDU 04-2014]
Page 4
