SAMAL ISLAND CITY COLLEGE Form No.
F-D2A11-071
Datu Taganiog Street, Brgy. Peñaplata,
Revision No. 00
Samal District Island Garden City of Samal, Davao del Norte
Email:
[email protected] Website: https://sicc.samalcity.gov.ph Date Effective 21 JANUARY 2025
ADMISSION APPLICATION FORM
Semester: [ ]1ST [ ]2ND A.Y.
Student Application No: Date of Application:
Type of Student: [ ]Freshmen [ ]Transferee [ ]Returnee [ ]Cross-Enrollee
ID Photo
Student Category: [ ]Full-time [ ]Working student, ____________
(Passport Size)
[ ]BS in Agribusiness [ ]BS in Entrepreneurship
Course Applied for: [ ]BS in Tourism Management [ ]BS in Criminology
[ ]Bachelor of Public Administration
l out this form carefully and PRINT or TYPE all information requested. Mark all appropriate boxes with an “/”. If item not applicable indicate “N/A”. Only
Application Forms correctly and completely filled out will be accepted, INCOMPLETE FORMS WILL NOT BE PROCESSED.
A. PERSONAL INFORMATION
Name: ___________________________________________________________________________________
[Last Name] [Given Name] [Middle Name] [Ext. Name: ex. Jr., Sr.]
Sex: [ ]Male [ ]Female Gender: [ ]Man [ ]Woman [ ]LGBTQ
Age: _____ Birthdate: _____________ Civil Status: [ ]Single [ ]Married [ ]Widowed [ ]Other: _________
(mm/dd/yyyy)
Home Address: _________________________________________________ Mobile Number: ___________________
Present Address: ________________________________________________ Email Address: ____________________
Place of Birth: __________________________________________________ Disability (if applicable): ___________
Senior High School/School Last Attended: ____________________________________ Year Graduated: __________
Senior High Track: __________________ Strand: ______________ LRN: ______________ GPA: ___________
Member of Cultural Minor Group? [ ] No [ ]Yes (Specify) _________________
(Ex. Sama, Manobo, Bagobo, etc.)
Father’s Complete Name: ______________________________________________________________________________
[Last Name] [Given Name] [Middle Name] [Ext. Name: ex. Jr., Sr.]
Mother’s Maiden Name: __________________________________________________________________
[Last Name] [Given Name] [Middle Name]
B. SOCIO-ECONOMIC DATA
RELATIONSHIP Highest
Family/ Household Members Mobile Occupation/ Monthly
(Relationship to Age Educational
(COMPLETE NAME) Number Livelihood Income
Applicant) Attainment
Note: Please include only members living in the same house. Total Monthly Income: __________________
Do you have family member who is an OFW? [ ]No [ ]yes, specify: ___________________
Is your family a beneficiary of any government social assistance program (ex. 4Ps)?
[ ]Yes, please specify the program: _________________________
Total amount received per month: _______________________
[ ]No
CONFORME: By signing below, I hereby certify that all the information written in this application are complete and accurate. I agree to
update the Office of Admissions and the Registrar’s Office for any changes. I acknowledge that I have read and understood the Samal
Island City College (SICC) Admissions Privacy Notice posted in the office premises. I understand that by applying for
admission/registering as a student of this institution, I allow SICC through the Office of Admissions to collect, record, organize, update or
modify, retrieve, consult, utilize, consolidate, block, erase or delete any information which are a part of my personal data for historical,
statistical, research and evaluation purposes pursuant to the provisions of the Republic Act No. 10173 of the Philippines, Data Privacy
Act of 2012 and its corresponding Implementing Rules and Regulations.
Remarks: Remarks:
_______________________________________ ________________________________ CATHERINE P. RABADON
Student’s signature over printed name SICCAT Admission In-Charge
