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MINDANAO STATE UNIVERSITY SYSTEM SENIOR HIGH SCHOOL

(This form is Not for Sale. No Fold/No Creases) ENTRANCE EXAMINATION (MSUS-SHSEE)
Cover shaded box with A PPL I CAT I ON
the sticker provided
FORM 6 9 0 0 0 Paste 2” x 2” ID photo in white
Requirements: background, with NAME TAG
1. Certification from High School Principal that the applicant is a Grade 10 student, or Form 138-A (Report Card), or inside this box.
Certificate of Completion from Bureau of Alternative Learning System (BALS) for out-of-school youth;
2. Two (2) copies 2” x 2” ID pictures; with complete name tag and white background; Important: DO NOT STAPLE.
3. Payment of Non-refundable Testing Fee of Php250.00; for Foreign students, $20. Pay directly to MSU University
Business Office (UBO), MSU Campus Registrar/Admission Officer/MSU SHSEE Test Center Coordinator at the Test Center
at least two days before the examination date or before December 14, 2017.
4. If filing at MSU-Marawi, proceed to the OVPAA-SASE to present the receipt from the University Business Office; and
5. Duly accomplished Application Form.
Instruction: Accomplish this form carefully. Make sure you double check that every required information is complete, correct, and accurate. Any wrong information can be
ground for disqualification either in taking the exam or in admission to MSU. Please PRINT all entries neatly and legibly USING BALLPEN. DO NOT LEAVE any blank
unfilled, ELSE, your application will not be processed. OVPAA/MSU-SASE Unit cannot and will not make any changes for your SHSEE Results of Rating other than what is
submitted in the Application Form.
WARNING and IMPORTANT NOTE: Before answering campus preferred, consult with Parents/Guardians.
Students from other PREFERRED CAMPUS MAY NOT BE ACCEPTED IN ANOTHER CAMPUS DUE TO LIMITED SLOTS.
1. MSU CAMPUS PREFERRED: ________________________________________ Test Center Code: ________________
Choose one Campus where you intend to study.: ( MSU-Marawi, MSU-Tawi-Tawi, MSU-Sulu, MSU-Maguindanao, MSU-Naawan, MSU-LNAC Sultan Naga Dimaporo,
MSU-Maigo School of Arts & Trades, MSU-LNCAT, MSU-Buug)
YOUR BIOGRAPHICAL DATA (as it appears on your high school record)
2. LAST NAME:
FIRST NAME:
MIDDLE NAME:
Sex  Male
3. Age: ______ 4. Gender:  Female 5. Civil Status:  Single  Married 6. Religion: ______________________ 7. Citizenship: _______________
8. Date of Birth: 9. Place of Birth: 10. Cellphone Number:
11. Present Address: 12. Zip Code: ____________
13. Permanent Home Address: 14. Zip Code: ____________
YOUR EDUCATIONAL BACKGROUND
15. NAME OF SCHOOL CURRENTLY ENROLLED: 16. Type of School:  Private  Public
17. ADDRESS OF SCHOOL:
FOR OUT-OF-SCHOOL YOUTH (OSY): 18. Year Graduated:
19. Preferred Mailing Address:
20. PREFERRED COURSES: Please refer below and make sure the program is available in your preferred campus. Write your preferred program.
[Tracks: STEAM (Science, Technology, Engineering, Agriculture & Mathematics), ABM (Accountancy, Business & Management),
HUMSS (Humanities & Social Sciences), & TVL (Technical-Vocational-Livelihood)]
1st Choice: 2nd Choice:
YOUR PARENTS’ DATA
FATHER MOTHER (Maiden Name)
NAME: 21. 22.

CONTACT NUMBER: 23. 24.

OCCUPATION: 25. . 26.

MONTHLY FAMILY INCOME: 27. 28.

ETHNIC ORIGIN/TRIBE: 29. 30.


(Ethnic Origin/Tribe of parents must be indicated. Example: Meranao, Tausog, Cebuano, Ilonggo, Higaonon, Kalagan, Kamayo, Maguindanao, Manobo, Mamanwa,
Mansaka, Sama, Jama Mapun, Kalibugan, Boholano, Iranun, Ilocano, Subanen, B’laan, T’boli, others, or not applicable (N/A)).

(Processor cuts along dashed line!) MSU SHSEE PERMIT 69000


NAME OF TAKER:
____________________________________________________________________________________________________ Paste 2” x 2” ID photo in
(Last Name) (First Name) (Middle Name) white background, with
NAME OF SCHOOL CURRENTLY ENROLLED: NAME TAG inside this box.
ADDRESS OF SCHOOL: Important: DO NOT
BRING THE FOLLOWING PLACE OF EXAM: STAPLE.
___________________________________________________________________
ON EXAMINATION DAY: Building Room No.
1. This Exam. Permit DATE: TIME:
2. School ID
PROCESSOR PRINTED NAME and SIGNATURE: STUDENT’S SIGNATURE:
3. Pencil (Lead No. 2)
4. Rubber Eraser
5. Blue or black Ballpen
Important: This slip serves as temporary receipt. Test Center Code:
Test Center Code:
Important Instruction:
29. Test Center Code: PRINT/SHADE the bubbles/circles using a dark lead30.pencil.
 Test Center Address:
Important Instruction: PRINT/SHADE the bubbles/circles using a dark lead pencil.

29. Test Center Code: PRINT/SHADE the bubbles/circles using a dark lead30.pencil.
Test Center Address:

_______________
Important

Instruction: 
29. Test Center Code: 30. Test Center Address:

_______________
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29.
31. Test
31.

LAST Center
NAME: Code:  FIRST NAME: 30.
32.Test Center Address: MIDDLE NAME:


_______________
31. _______________
LAST NAME: FIRST NAME: MIDDLE NAME:
  
31. 
LAST NAME: FIRST NAME:
 MIDDLE NAME:

31.
33.LAST NAME: 
 FIRST NAME:

 MIDDLE

 NAME:
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
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



  

 

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
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 

 

 




  
 




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
 

 


 





  


 
 



 

 


  





  
 



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
 
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
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

  

 

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



 
 


 




  

 

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
 
 


 




  
 

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
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
 
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 
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
 





  


 
 



 

 


 





  

 






 
 

 




  

 






 
 

 


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

  








 
 








  


 
 



 
 







  

 






 

 


 





  

 






 
 


 





  





 



 
 


 





  
 







 
 







  


 
 



 
 

 




  

 

 




 
 






 
  

 







 
32. Gender
Sex


  

33. Civil Status 




 


I32. Gender
Sex
hereby 
certify that  on this form are33.
all entries trueCivil
and Status
correct.  

32.
I34. Gender
Sexcertify that
hereby   on this form are33.
all entries trueCivil
35. and Status
correct.  36. LRN No.:
32. Gender
Sex  33. Civil Status 
34. Applicant’s Signature over Printed Name: ________________________________________________________________ Date: _____________________________
I hereby certify that all entries on this form are true and correct.
I34.
hereby
37. certifySignature
Applicant’s that all entries on this
over Printed form ________________________________________________________________
Name: are true and correct. Date: _____________________________
34.
35. Applicant’s Signature
Parent’s/Guardian’s over Printed
Signature Name: ________________________________________________________________
Name: _____________________________________________________ Date:
Date:_____________________________
38.
34. Applicant’s Signature over Printed over
Name:Printed
________________________________________________________________ Date: _____________________________
_____________________________
35. Parent’s/Guardian’s Signature over Printed Name: _____________________________________________________ Date: _____________________________
35. Parent’s/Guardian’s Signature over Printed Name: _____________________________________________________ Date: _____________________________
35. Parent’s/Guardian’s Signature over Printed Name: _____________________________________________________ Date: _____________________________

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