PERSONAL HISTORY STATEMENT

(1)

Lasallian Access & Success Office

City of Dasmariñas, Cavite, Philippines

Cavite: (63) (46) 481-8000 Manila: (63) (2) 988 3100 Local/ Telefax: 8032 | 1451 (Office of the Director) 5001 (Admission and Testing) | 1407 (Scholarships) 1406 (Marketing and Recruitment)

www.dlshsi.edu.ph

PERSONAL HISTORY STATEMENT

(To be accomplished completely and submitted by the foreign applicants in three (3) original copies to De La Salle Health Sciences Institute Lasallian Access & Success Office)

1.0 PERSONAL DATA

1.1 Name:

_____________________________________________________________________

(Last Name) (First Name) (Middle Name)

1.2 Name in Native Language Character:

_____________________________________________________________________

1.3 If Married: Woman, State Maiden’s Name ____________________________________

Man, Name of Spouse: __________________________________________________

1.4 Address: (Permanent, Abroad):_____________________________________________

Philippines: __________________________________________

1.5 Age: _______1.6 Date of Birth: ______________________

1.7 Place of Birth: _________________________

1.8 Citizenship: ___________________________

1.9 Religion: _____________________________

2.0 PHYSICAL DESCRIPTION

2.1 Sex: ________ 2.2 Height: ________ 2.3 Weight: _____________

2.4 Eyes: _______ 2.5 Hair: __________ 2.6 Complexion: __________

2.7 Built: _______ 2.8 Other Distinguishing Features: _______________________

2.9 Physical Handicap or Disability (if any): _______________________________________

3.0 FAMILY DATA

3.1 Name of Father: _________________________________________________________

3.2 Name of Mother: ________________________________________________________

3.3 Address: _______________________________________________________________

4.0 EDUCATIONAL BACKGROUND

Name of School Date of Attendance Course Finished

4.1 Elementary: _______________________________________________________________

4.2 High School: ______________________________________________________________

4.3 College: __________________________________________________________________

4.4 Post Graduate: _____________________________________________________________

LASO FORM 014012

(2)

Lasallian Access & Success Office

City of Dasmariñas, Cavite, Philippines

Cavite: (63) (46) 481-8000 Manila: (63) (2) 988 3100 Local/ Telefax: 8032 | 1451 (Office of the Director) 5001 (Admission and Testing) | 1407 (Scholarships) 1406 (Marketing and Recruitment)

www.dlshsi.edu.ph

5.0 GENERAL QUALIFICATION

5.1 Language Grade Proficiency (Oral or Written)

________________________ __________ ___________________________________

5.2 Hobbies: ______________________ 5.3 Sports:_________________________

5.3 COURSE APPLIED FOR: __________________________________

Semester: [ ] First [ ] Second School Year: ___________________

Trimester: [ ] First [ ] Second [ ] Third School Year: ___________________

I CERTIFY THAT THE FOREGOING ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

Signed at ___________________________________ Date _________________________

______________________________

Signature of Applicant

A True Copy:

TYD/gpp/fn: phs/folder: foreign student

(Signed photograph

of applicant to be affixed here)

Left Thumb mark Right Thumb mark

AOAS FORM 014012