PHS (Revised 1998)

PERSONAL HISTORY STATEMENT

(To be accomplished completely and submitted by the applicant foreign student in six (6)
original copies to the college or university he/she is seeking admission into)
1.0

PERSONAL DATA
1.1
1.2
1.3
1.4

1.5
1.8
2.0

PHYSICAL DESCRIPTION
2.1
2.4
2.7
2.8

3.0

Sex : ________ 2.2 Height ______________ 2.3 Weight _____________

Eyes: ________ 2.5 Hair ________________ 2.6 Complexion __________
Built: ________ 2.8 Other Distinguishing Feature : ___________________
Physical Handicap or Disability (if any): ____________________________

FAMILY DATA
3.1
3.2
3.3

4.0

Name: _______________________________________________________
(Last Name)
(First Name)
(Middle Name)
Name in Native Language Character: ______________________________
If Married:
Woman, State Maidens Name: _______________________
Man, Name of Spouse: ______________________________
Address:
(Permanent, Abroad): _______________________________
_________________________________________________
Philippines: ______________________________________
_________________________________________________
Age: ____ 1.6 Date of Birth: __________ 1.7 Place of Birth ___________
Citizenship: ____________________ 1.9 Religion __________________

Name of Father: _______________________________________________

Name of Mother: ______________________________________________
Address: _____________________________________________________

EDUCATIONAL BACKGROUND
Name of School
4.1
4.2
4.3
4.4

Date of Attendance

Course Finished

Elementary: __________________________________________________
High School: _________________________________________________
College: _____________________________________________________
Post Graduate: ________________________________________________

5.0

6.0

GENERAL QUALIFICATION
5.1

Language
Grade of Proficiency (Oral or Written)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

5.2

Hobbies: ________________________________ 5.3 Sports: ______________

COURSE APPLIED FOR: ________________________________________________

Semester:
Trimester:

[ ] First
[ ] First

[ ] Second
[ ] Second

[ ] Third

School Year __________

School Year __________

I CERTIFY THAT THE FOREGOING ANSWER ARE TRUE AND CORRECT TO

THE BEST OF MY KNOWLEGDE AND BELIEF.

Signed at _________________________________ Date _______________________

____________________________
(Signature of Applicant)

(Signed photograph
of applicant to be
affixed here)

A true copy:
/babylee fn:phs_frm disk: nbq1

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