Republic of the Philippines

LEYTE NORMAL UNIVERSITY

DIRECTOR OF THE ADMISSIONS OFFICE
P. Paterno St., Tacloban City
-o0o-

APPLICATION FOR COLLEGE ADMISSION FORM

Instructions:

1. Read the guidelines before filling out the form.

2. Fill out the form carefully and completely. Passport Size ID
3. Only complete forms will be accepted. Picture
4. Submit all required documents by the deadline. White background
5. Incomplete applications won't be processed. name tag.
6. Submitted documents become the property of the University and won't be returned.

COLLEGE OF _____________________________________

Application Details:
Entry Status: Academic Year: ___1st Semester ___2nd Semester ___Summer, SY 20__ - 20__
Freshman
Transferee PROGRAM PREFERENCE
2nd Courser (See list of programs offered by the University.)

__________________________________________
Program Name

PERSONAL INFORMATION

Applicant’s Name as in Birth Certificate:

________________________________________________________________________________________
Family Name First Name Middle Name
Date of Birth: ______________________ Age: _______ Gender: ________ Status: ________________
(Month, Day, Year)
Place of Birth: _________________________________ Citizenship: _______________________________
(City / Town, Province)
Permanent Home Address: ______________________________________________________________
(House Number, Street, Barangay, Town/City, Province, Zip Code)
Mailing Address (If not the same as above):
________________________________________________________________________________________
(House Number, Street, Barangay, Town/City, Province, Zip Code)

Religion:__________________ Mobile Number: _______________ E-mail Address: ___________________

FAMILY BACKGROUND

FATHER MOTHER GUARDIAN

(If not living with parents)
Name

Citizenship

F-ADM-001 Rev. 1 (11-10-23)

 Contact Numbers

E-mail Address

Occupation/Position
(If employed)

Employer’s Address

EDUCATIONAL BACKGROUND

Learner’s Reference Number (LRN) as reflected in your report card or Form 138: _____________________

Name of School Address Year Honors Received

Graduated
Kindergarten

Elementary

Junior High School

Senior High School

College transferees and second coursers,

please list down all universities/colleges
attended.

Other Pertinent Information

Do you have previous application at Leyte Normal University? ( ) Yes ( ) No.

If yes, kindly indicate the Academic Year: ________
What are your hobbies, talents and interests? __________________________________________
Are you a member of any club or organization? ( ) Yes ( ) No. If yes, kindly indicate the name of the organization
or club: ___________________________________________________________
Do you have any PHYSICAL DISABILITY and/or CONDITION that requires additional support, special attention or
that should be taken into consideration in planning your academic activities?
( ) No ( ) Yes (specify) ________________________________________________________
______________________________________________________________________

(If necessary, please attach medical certificate and/or psycho-educational assessment report.)

F-ADM-001 Rev. 1 (11-10-23)

 CHARACTER REFERENCES: Write down at least two (2) names and addresses of persons as character references
(teachers/advisers, guidance counselors, barangay officials, pastors).

Name Address Contact Number

PERSONAL STATEMENT:

Explain your purpose in seeking admission to the University and the goals which you want to achieve.

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________.

I understand that my application for admission is subject to approval of the Admissions Committee of the University.
By signing below, I certify that the information given is true and correct. Falsifying any of the information is sufficient ground
for any legal action and rejection relative to my application. In addition, I understand that LNU has no obligation to provide
me with reasons in case this application will be denied.

I know that the information collected relates to my admission and will be handled, processed, protected, shared,
retained and used by the University for its Pursuit of legitimate purposes.
I AGREE that the data pertaining to screening will be treated for:
• verification of my identity and determination of my eligibility to enroll in LNU;
• collection and records keeping during my stay in the University;
• publication/posting of my name, if qualified;
And shall be:
• destroyed one (1) year after my graduation/transfer;
• used for reporting for and by the Admissions Director, Guidance and Testing Office, and the University;
and
• Used for creating programs and activities of the Admissions Office and the Guidance and Testing
Office.
I AGREE further that if qualified to be a student of Leyte Normal University, I shall abide by all the rules and
regulations of the University.

Admissions Office Remarks

_________________________________ _________________
Signature over Printed Name Date

F-ADM-001 Rev. 1 (11-10-23)

 DATA PRIVACY CONSENT FORM

The undersigned (name) _________________ is a student/employee/client of Leyte

Normal University (LNU), understands the importance of the protection and confidentiality
of personal data in compliance with Republic Act No. 10173, also known as the Data
Privacy Act of 2012.

By signing this consent form, I grant my free, voluntary, and unconditional consent to
the collection, processing, storing, and sharing of my Personal Data (as defined below),
including any information or records, relating to me disclosed by me, online or in person,
or by my authorized representative to Leyte Normal University or any of its authorized
representatives as information controller, by whatever means in accordance with RA
10173 and its IRR.

I understand that “Personal Data” that may be collected includes the following: (a) full
name, contact details, address, date of birth, and identification numbers; (b) email
addresses, IP addresses, and other online identifiers; (c) photographs and videos taken
during official university events; (d) race, ethnic origin, marital status, age, color, and
religious, philosophical, or political affiliations; (e) health, education, genetic or sexual life
of a person, or to any proceeding for any offense committed or alleged to have been
committed by such individual, the disposal of such proceedings, or the sentence of any
court in such proceedings; (f) information issued by government agencies peculiar to an
individual which includes, but is not limited to social security numbers, previous or current
health records, licenses or its denials, suspension or revocation, and tax returns.

I acknowledge and agree that my personal data will: (1) be treated with utmost
confidentiality and stored securely (2) be shared with authorized government agencies,
accrediting bodies, and third-party service providers for legitimate purposes; (3) be used
for documentation and promotional purposes, including photographs and videos taken
during official university events.

I understand further, that LNU shall keep the personal data and information or records,
in strict confidence, and that the collection, processing, storing, and sharing of all
personal data and/or information by LNU may be used for any of the following legitimate
purposes the (“Purposes”): (1) facilitating enrollment, employment, and other official
transactions with the university; (2) sending official notices, updates, announcements,
and other correspondence to stakeholders; (3) verifying identity for securing access to
university premises, systems, and resources; (4) supporting the delivery of academic
programs, research initiatives, and related activities; (5) providing personalized guidance,
counseling, and accommodations for the well-being of students; (6) documenting and
showcasing university programs, events, and achievements through publications and
media; (7) fulfilling legal, regulatory, and statutory obligations, including tax, insurance,
and social security requirements; (8) upholding anti-discrimination policies and creating
programs that cater to the needs of a diverse community; (9) ensuring appropriate
measures are in place to safeguard the health and safety of individuals; (10) conducting
demographic studies, improving services, and supporting policy-making; (11) maintaining
accurate and reliable records for governance, audits, and historical documentation; (12)
enabling access to online platforms, ensuring cybersecurity, and improving digital
resources; (13) managing and resolving complaints, disciplinary actions, or legal
proceedings in a confidential manner; (14) confirming qualifications for scholarships,
grants, employment, or other university benefits; and (15) maintaining contact and
fostering relationships with alumni and other stakeholders for networking and
collaboration.

I acknowledge that I am made aware of my rights as a Data Subject, in accordance with

the Data Privacy Act of 2012, to wit:

i. to be informed whether Information and/or Personal Data is being or has been

processed;
ii. to require LNU to correct any Information and/or Personal Data relating to the
Data Subject which is inaccurate;
iii. to object to the processing of the Information and/or Personal Data in case of
changes or amendments to the Information and/or Personal Data supplied or
declared to the Data Subject;
iv. to access the Information and/or Personal Data;
v. to suspend, withdraw or order the blocking, removal or destruction of the Data
Subject's Personal Data from LNU's information database system;
vi. Be indemnified for any damages sustained due to such inaccurate, incomplete,
outdated, false, unlawfully obtained or unauthorized use of personal information.

I have read and understood the above and hereby consent to, agree on, accept, and
acknowledge these terms of consent for myself and/or as agent/s for and on behalf of
the principal/s I represent by signing below.

Signed in Tacloban City on ___________, 202__.

_____________________________
Signature over Printed Name

If the Student/Client is a Minor:

____________________________
Signature over Printed Name of the Parent/Guardian