Exchange Student Application Form

(1)

Academic Linkages

De La Salle-College of Saint Benilde

Taft Campus 2544 Taft Avenue,

Malate, Manila 1004

Tel Nos.: (02) 230 5100 loc. 1136

Email: [email protected]

Office Hours: Mon.-Fri. 8:00am-12:00nn

1:30pm-5:00pm

(As stated in Birth Certificate. Please PRINT or TYPE.) STUDENT APPLICANT Surname

First Name

Middle Name

Nickname

Gender Male Female

(Assigned ID Number once applicant is enrolled

Exchange Student Application Form

Fill up this form and accomplish all admission requirements indicated herein:

1) Scanned copy of Transcript of Records with GPA

2) Scanned copy of Birth Certificate

3) Scanned copy of Passport bio page (w/ at least 6 months validity during the

program)

4) Curriculum Vitae

5) Letter of Recommendation from the home university

6) Medical Clearance from the School Physician

7) Accomplished attached BENILDE Exchange Student Forms/Waivers

For the

1

st

Trimester

3

rd

Trimester

2

nd

Trimester

School Year

to

PERSONAL INFORMATION

Mailing Address (WRITE LEGIBLY. Mailed application status letter are sent to this address.)

Three 2x2 Colored

Picture

w/ white background

(Attach 1 copy)

Zip Code

Permanent Address Zip Code

Date of Birth (MM/DD/YYYY) Place of Birth

Age Height Weight

Email Address

Home Telephone Number Mobile Number

Citizenship

Religion

Civil Status If married, name of spouse

(2)

ACADEMIC INFORMATION

Home College (FULL OFFICIAL NAME)

Complete Address Program Chairperson

Contact Details (contact # / email address)

Program/Degree/Major Field of Study

Period Attended/Honors and Awards (if there are any)

EMERGENCY CONTACT IN HOME COUNTRY

Name and Relationship to Applicant (parent/guardian)

Contact Number (Home)

Contact Number (Work)

Contact Number (Mobile)

I CONFIRM THAT I WILL PAY THE TUITION FEE AT MY HOME UNIVERSITY FOR THE COMPLETE

TRIMESTER IN DE LA SALLE-COLLEGE OF SAINT BENILDE IN ADVANCE.

I certify that the information given herein is correct and complete. Falsification, misrepresentation,

or withholding of information requested in this form will automatically nullify my application and/or

subject me to dismissal from De La Salle-College of Saint Benilde “BENILDE”.

I recognize that it is my responsibility to provide all documentary evidence requested in this

application. I authorize the College to obtain further information where deemed necessary. I agree

to comply with College rules governing admission and enrollment and policies on the student

exchange programs.

I, herby give my consent to BENILDE, its affiliates and assigns, to use my name, image, portrait,

pictures, video and audio, for publicity, educational, advertising, and public relations purposes

anywhere in the world, or without restrictions as to frequency or duration of usage.

I, herby waive any right that I may have to inspect and/or approve the finished product or the

advertising that may be used in connection herewith, or the use to which it may be applied.

(3)

Finally, I understand that I am responsible for the prompt payment of any related fees as required

in the program I am applying for.

Date Signature

REMEMBER TO KEEP COPIES FOR YOUR OWN INFORMATION.

Submit this form, together with all accomplished admission

requirements, by emailing it at

[email protected] by courier to:

De La Salle-College of Saint Benilde Academic Linkages

Office of the Chancellor

2nd_{fl. Taft Campus, 2544 Taft Avenue,}

Malate, Manila 1004 Philippines

Academic Calendar and Deadlines of Submission of Application Forms

De La Salle-College of Saint Benilde has three trimesters in its Academic Calendar:

a. 1st Trimester (August – December) b. 2nd Trimester (January – April) c. 3rd Trimester (April – August)

An Inbound Exchange Student can enter in any of the three trimesters. Partner schools are encouraged to submit their nominations for Inbound Exchange Students on the following days: a. 1st Trimester entry: April 30 of every year

b. 2nd Trimester entry: September 30 of every year c. 3rd Trimester entry: November 30 of every year

NOTE: Submit complete student requirements / documents a months after.

(4)

BI FORM CGAF

CONSOLIDATED GENERAL APPLICATION FORM

FOR STUDENT VISA AND SPECIAL STUDY PERMIT

II. APPLICANT’S TRAVEL INFORMATION

Passport Number

Expiry Date/Valid Until [DD-MMM-YYYY e.g. 01 JAN 1990] Place of Issuance

III. APPLICANT’S PERSONAL INFORMATION

Last Name First/Given Name Middle Name

Date of Birth [DD-MMM-YYYY e.g. 01 JAN 1990 Citizenship/Nationality

Height [cm]

Contact Number(s) in the Philippines

Landline Mobile

Residential Address in the Philippines House/Unit No., Street, Subdivision/Village Barangay, Municipality/City

Province, Zip Code

IV. GUARDIAN’S INFORMATION

Name of Guardian [Last Name, First/Given Name, Middle Name] Relationship with the Applicant

Residential Address in the Philippines House/Unit No., Street, Subdivision/Village Province, Zip Code

Contact Number(s) in the Philippines Landline

V. SCHOOL’S INFORMATION

Name of School

School Accreditation Number

Residential Address in the Philippines House/Unit No., Street, Subdivision/Village Province, Zip Code

Contact Number(s) in the Philippines Landline

Attach your 2x2 colored photograph with white background using

permanent glue in the photograph box. The photograph must be taken within the last three (3) months from the date of application. A scanned photograph is not allowed. A photograph of the applicant wearing eyewear (i.e. sunglasses, colored contact lenses, etc.) or headwear is not acceptable.

BI FORM CGAF-003-Rev 1

This document may be reproduced and is

CONSOLIDATED GENERAL APPLICATION FORM

FOR STUDENT VISA AND SPECIAL STUDY PERMIT

I. APPLICATION INFORMATION

Present Immigration Status Nature of Application

Conversion Extension Permit Course/Degree

Number of Months/Year Applied for Months 1 Year

Name of School Representative [Last Name, First/Given Name, Middle Name]

School Representative Identification Number

II. APPLICANT’S TRAVEL INFORMATION

Date of Latest Arrival [DD e.g. 01 JAN 1990] Flight Number

Last Day of Authorized Stay [DD

III. APPLICANT’S PERSONAL INFORMATION

e.g. 01 JAN 1990] Gender Country of Birth M F

Civil Status Single Weight [kg] Separated

Special Security Registration Number (SSRN

Email Address

Residential Address Abroad

House/Unit No., Street, Subdivision/Village City, State

Country, Zip Code

Last Name, First/Given Name, Middle Name]

Barangay, Municipality/City Country, Zip Code

Mobile

Barangay, Municipality/City Country, Zip Code

Mobile

This document may be reproduced and is

NOT FOR SALE

CONSOLIDATED GENERAL APPLICATION FORM

FOR STUDENT VISA AND SPECIAL STUDY PERMIT

Page 1 of 2 Type of Application

Student Visa Special Study Permit

School Year - [Last Name, First/Given Name, Middle Name]

Date of Latest Arrival [DD-MMM-YYYY e.g. 01 JAN 1990] Flight Number

Last Day of Authorized Stay [DD-MMM-YYYY e.g. 01 JAN 1990]

Married Annulled Widowed Divorced

Special Security Registration Number (SSRN)

Residential Address Abroad

House/Unit No., Street, Subdivision/Village

Barangay, Municipality/City

(5)

BI FORM CGAF-003-Rev 1

This document may be reproduced and is

NOT FOR SALE

CONSOLIDATED GENERAL APPLICATION FORM

FOR STUDENT VISA AND SPECIAL STUDY PERMIT

Page 2 of 2

Registered Address of School

Room No., Floor No., Building, Street Barangay, Municipality/City

Province, Zip Code Country, Zip Code

Contact Number(s) in the Philippines

Landline Mobile

VI. ACR I-CARD

Alien Certificate of Registration (ACR) Number Date of Issuance [DD-MMM-YYYY e.g. 01 JAN 1990] Expiry Date/Valid Until [DD-MMM-YYYY e.g. 01 JAN 1990] Certificate of Residence Number (CRN)

Recommending Approval:

_____________________________________

(Signature over Printed Name)

Date Signed: ________________

APPROVED/DISAPPROVED:

RONALDO A. GERON

Commissioner

Date Signed: ________________

DO NOT FILL OUT THIS PORTION

Application Number

Received/Recommended by: ________________________________ Reviewed by: ____________________________________________ Approved by: ____________________________________________

“VISA IMPLEMENTATION STAMP”

Immigration Control (IC) No.:

Period of validity [DD-MMM-YYYY e.g. 01 JAN 1990]:

From

Until

Official Receipt Numbers:

a) _____________________________________________

b) _____________________________________________

c) _____________________________________________

(6)

O

FFICE OF THE

R

EGISTRAR

2544 Taft Avenue, Manila, Philippines 1004 Phone No. (632) 230-5100 loc. 3323, 3324, & 3325

Direct Line: (632) 525-8809 | Telefax: 536-4225 http://www.dls-csb.edu.ph/registrar

(ID Number) (School/Degree Program)

Registration Form

(EXCHANGE STUDENTS)

Personal Information:

____ _ ____________________

Family Name

Full Given Name

Suffix

(Jr., Sr., II)

Middle Name

Mailing Address:

_______________________________________________________________________________________

House or Bldg # / Street / Brgy or Subdivision /Town /District

Permanent Address:

____________________________________________________________________________________

House or Bldg # / Street / Brgy or Subdivision /Town /District

Male

Single

Place of Birth

:___________________________________

E-mail

:_____________________________

Female

Married

Date of Birth

:___________________________________

Landline #

:_____________________________

Nationality

:___________________________________

Mobile #

:_____________________________

Father’s Name: _______________________________________

_____

Mother’s Maiden Name: _____________________________

_______

Educational Information:

Name and Address of School

Date Graduated

Degree Taken

High School

College / Vocational

Graduate Study

Work Information:

Position

Company Name and Address

HRD Head / Contact Number

Verification / Authorization:

I have carefully read the contents of this application form. I certify that the information given herein is correct and complete.

Falsification, misrepresentation, or withholding of information requested in this form will automatically nullify my application and/or subject me

to dismissal from De La Salle-College of Saint Benilde.

This also authorizes any school I have previously attended to release any information/records requested by De La Salle-College of

Saint Benilde in relation to this application. The College may use such information in the processing of this application.

_________________________________________

_____________________

Printed Name & Signature of Applicant

Date

Application Form Assessed by:

Printed Name & Signature

Date

(Program Associate or Secretary)

RO ExSt Admission Form 041012

Reminders:

Please fill-out the form legibly and completely.

Write “N/A” for fields that are not applicable.

Do not use nick name.

Use the name that appears in your previous school records.

Submit admission requirements together with this form.

PHOTO

(2X2)

(7)

O

FFICE OF THE

R

EGISTRAR

2544 Taft Avenue, Manila, Philippines 1004 Phone No. (632) 230-5100 loc. 3323, 3324, & 3325 Direct

Line: (632) 525-8809 | Telefax: 536-4225 http://www.dls-csb.edu.ph/registrar