COLLEGE OF SAN BENILDO - RIZAL

GRADE SCHOOL/HIGH SCHOOL/COLLEGE DEPARTMENT

Marcos & Sumulong Highway, Rizal

APPLICANT’S INFORMATION SHEET

(Non-Academic)

Print or write legibly all answers to this questionnaire. Put an X on the questions requiring YES - NO response.
NA for those that are not applicable. Thank you.

Date: _____________________
02/28/2023

Gonzales Goldwin Joseph

I. A. Name: _______________________________________________________________________________________ Baccay
(Family Name) (First Name) (Middle Name)
B. Date of Birth: _____________________________________
December 6, 1996 Place of Birth: ________________________________
Antipolo City
C. Religion: _________________________________________
Roman Catholic Citizenship: ________________________________
Filipino
D. Status: ____ Single
x ____Married ____Widow(er)
E. City Address: ___________________________________________________________________________________
Phase 2 Blk 2 Sitio San Lorenzo Ruiz, Brgy, San Roque Antipolo City Rizal
Tel. No. _____________ Mobile No. 09483049469
__________________ E-mail address: [email protected]
________________________
Provincial Address: _________________________________________________
Antipolo City, Rizal Tel. No. ____________________
F. Tax Identification Number: _______________________________________
472-877-663-000 SSS: __________________________
34-5109123-8

II. FAMILY
A. Name of Spouse: ____________________________________________________ Religion: _________________
B. Is spouse employed? YES: ___ NO: ___
C. If “Yes” where? _________________________________________________________________________________
D. Office Address: ________________________________________________________ Tel. No.: ________________
E. Dependents:
Name Relationship Age
_____________________________ ________________________ ____________
_____________________________ ________________________ ____________
_____________________________ ________________________ ____________
_____________________________ ________________________ ____________

III. Parents:
A. Father’s Name: _________________________________
Gerry Gonzales (deceased) Citizenship: ____________
Filipino Religion: Roman
______________
Catholic
Address: _______________________________________________________________________________________
Place of Employment: ___________________________________________________________________________
B. Mother’s Name: Ma. _________________________________
Cherry Rufina Gonzales Citizenship: Filipino
____________ Religion: ______________
Roman Catholic
Address: __________________________________________________________________ Tel. No. ____________
Sitio San Lorenzo Ruiz, Brgy. San Roque, Antipolo City
Place of Employment: ___________________________________________________________________________

IV. Educational Qualification

School/College/University Place/Address Year Degree, Title, Diploma,
Graduated Honor Received
Post Graduate Studies

Collegiate ICCT Colleges BS-IT

Antipolo City 2022
*Special Training

High School San Roque National High School Marigman St., Antipolo City
2014
Elementary Juan Sumulong Elementary School J. Sumulong Street, Antipolo City
2010

V. Work Experience (start from latest)

A. Government Service
Government Agency/Office Inclusive date of Salary Cause of Separation
employment

B. Private Institution
Name of Institution Inclusive date of Salary Cause of Separation
employment
 C. Will you be entirely dependent on your salary if employed?
Yes: _____
X No: _____ If not, state source of income: __________________________________________________
D. What position of job are you applying for? ___________________________________________________________
IT Staff
E. What is the lowest entrance salary that you would accept?
Exclude living allowance: Php ________________________
12,000 - 15,000
F. Do you have relatives employed or enrolled at CoSB-R? _____________
None
If yes, state name and position/grade level of student: ________________________________________________
G. Do you have any pending application in the public schools? None
_____________________________________________
H. Are you currently employed? Yes: ______ specify: __________________ No: ______________
X
Full time: ________ Part time: ___________
I. Do you have a stable internet connection? What type: DSL ___Fiber optic broad band ___wireless
X ___Mobile Data_____
J. Internet Service Provider: ___Globe ___Smart ____ PLDT ____ PT&T ____Converge ___DITO
X others ________
K. What are your hobbies? ___________________________________________________________________________

VI. Personal Integrity/Health

A. Have you been arrested or convicted of any violation of the law other than minor traffic violation?
Yes: ____ No: ____
X
If yes, state the name of the court, address, nature of the offense and disposition of the case and/or penalty
Imposed _______________________________________________________________________________________
_______________________________________________________________________________________________
B. Have you had any sickness, physical defect or disability, nervous breakdown or any epileptic attack and/or
suffering from allergy or asthma? Yes: ___ No: ___
X
Give full particulars if your answer to the above is affirmative: __________________________________________
_______________________________________________________________________________________________

C. Have you been fully vaccinated for Covid-19? Yes: ______

X Type of vaccination: _______________
sinovac No: _________
1 dose date: __________
st 8-24-2021 2 dose date: _______________
nd 9-21-2021 booster shot:____________

D. Have you been involved in any civil case? YES: ______ NO: _________
x
Give full particulars if your answer is affirmative.

____________________________________________________________________________________________________________
________________________________________________________________________________________

E. Person to be notified in case of emergency:

Ma. Cherry Rufina B. Gonzales Mother

_________________________________________ __________________________
(Name) (Relationship)

Sitio ______________________________________
San Lorenzo Ruiz Brgy San roque Antipolo City Rizal 09458655546
________________________
(Address) (Tel. No.)

F. Two specimen of your signature and initial:

Signature: ___________________________ Initial: __________________________
___________________________ __________________________

Write in a 10-sentence paragraph describing your response to the question “Why do you want to become a part of College of
San Benildo – Rizal Academic Community?
____________________________________________________________________________________________________________
As a fresh graduate student, it is an honor to be part of an educational institution that is well known here in our country.
____________________________________________________________________________________________________________
The first reason I like to be part of the San Benidlo-Rizal Academic Community is because it centers on Christian values.
____________________________________________________________________________________________________________
I always dream of working at a school that supports and improves its technology-based education, so it is really my
____________________________________________________________________
desire to work with this school. Since I'm also living in Antipolo, I don't have a problem dealing with too much traffic. I
____________________________________________________________________________________________________________
also see this as an opportunity to give my best in my work as well as show my talents and knowledge in the field that I
____________________________________________________________________________________________________________
studied. I know I can help this institution provide a quality education for its students.
______________________________________________________________________________
____________________________________________________________________________________________________________
________________________________________________________________________________________

VII. I certify that the foregoing information/statements are true and correct to the best of my knowledge and belief.

________________________________
Signature of Applicant
VIII. References
Previous Employer Address Contact No.
__________________________ __________________________ ___________________
__________________________ __________________________ ___________________
__________________________ __________________________ ___________________
__________________________ __________________________ ___________________

Documents to be submitted (bring original copy):

______ Transcript of Records ______ Two (2) 1x1 pictures
______ LET and other professional credentials ______ TIN
______ Birth Certificate ______ Photocopy of SSS B-1/E Form
______ Baptismal Certificate ______ Photocopy of Community Tax Certificate
______ Catholic Marriage Contract (if married) ______ Police Clearance/NBI Clearance
______ Results of medical check-up by the physician ______ Recommendation from previous employer/Character Reference
including x-ray, blood, urine and stool tests

Note: All documents submitted by the applicants pertinent to his/her application to College of San Benildo- Rizal will remain property of the school.