DON MARIANO MARCOS MEMORIAL STATE UNIVERSITY
NORTH LA UNION CAMPUS
Bacnotan, La Union
STUDENT AFFAIRS SERVICES
Latest
GUIDANCE AND COUNSELING UNIT
2” x 2”
INDIVIDUAL INVENTORY photo
INSTRUCTIONS:
Your Guidance Counselor would like to get information about your personal life as
a student to enable her to give the necessary assistance. In this connection, it is Course: _______________
requested that you answer the questionnaire honestly by checking/ supplying the I.D. No.: ______________
answer/s most appropriate for you. Be assured that all the responses will be
handled with the highest level of confidentiality.
I. PERSONAL DATA
Name: _______________________________________________________________________________
(Please Print) LAST NAME FIRST NAME MIDDLE NAME
Citizenship: ______________ Sex: ( ) Male ( ) Female ( ) Gender: ( ) Masculinity ( ) Femininity
Civil Status: ( ) Single ( ) Married ( ) Widow/er ( ) Legally Separated
Date of Birth: ___________________ Place of Birth: _____________________ Age: ________
Birth order among siblings: ______ Religion: __________________________
Home Address: ______________________________________ Contact #: ________________________
Facebook Account: ______________________ E-mail Address: ___________________________
Physical Disability, pls. specify: _______________________ PWD ID NO.: ______________________
Present/Boarding House Address: _______________________________________________________
Landlady’s/Landlord’s Name: _________________________ Contact #: ________________________
Do you belong to indigenous group? If yes, specify _________________________________________
II. FAMILY BACKGROUND
FATHER(pls. indicate + MOTHER (pls. indicate + if GUARDIAN (if not living w/
if deceased) deceased) parents)/ SPOUSE (if married)
Name:
Date of Birth:
Address:
Mobile No.:
Highest Educational
Attainment:
Occupation:
Place of Work:
Monthly Income:
Language Spoken:
Religion:
NAME OF SIBLINGS (Brothers/Sisters) AGE CIVIL STATUS SCHOOL/PLACE OF WORK
Parents are:
Living Together Mother with another partner _Father with another partner
Separated Mother is an OFW Father is an OFW
Legally Separated Mother is dead Father is dead
Person to contact in case of emergency: Mobile #:
For MARRIED/SINGLE PARENT students:
Name of Children Age School
III. EDUCATIONAL BACKGROUND
a. Scholastic Record
Name of School Address Inclusive
dates of
attendance
JUNIOR HIGH SCHOOL
SENIOR HIGH SCHOOL
Last School Attended
b. Scholastic Record (DMMMSU-NLUC)
YEAR GRADE POINT AVERAGE (GPA)
ACADEMIC COURSE LEVEL Scholarship Grant 1st 2nd
YEAR Semester Semester Midyear
IV. CAREER/ INTEREST INFORMATION
Course Preference: 1. __________________ 2. __________________ 3. ___________________
Reason/s for these preferences?
___ Personal Choice ___ Suggested by others
___ Parent’s Choice ___ Others (please specify): _____________________________________
Who finance your studies? _________________________________________________________
Special Skills/Talents/Hobbies: ________________________________________________________
Membership in an organization/s:
In School
Name of Organization Position Academic Year
Outside of School
Name of Organization Position Academic Year
V. HEALTH DATA
Information about health: ___________________________________________________________________
I hereby certify that the information I have given as called for in this form are true and
correct to the best of my ability.
________________________________________________________ _________________________________
SIGNATURE OVER PRINTED NAME DATE
COUNSELOR’S REMARKS
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