Annex 3

Department of Education
Senior High School Registration Form

TO THE STUDENT AND PARENT/GUARDIAN: Print legibly all information required. Place X marks in appropriate boxes.

1. NAME OF STUDENT: Print or type your full name in the following sequence: LAST, FIRST, MIDDLE. 2. GENDER Male Female
Place one letter in each box.

3. DATE OF BIRTH (Month, Day, Year)

LAST
W I B I S ONO
FIRST 17 - 04 - 2004
OB ED
MIDDLE -

4. PLACE OF BIRTH (City/Town or Province) S I T U B O N D O 5. NATIONALITY INDONESIAN

E A S T J A V A

6. ELEMENTARY SCHOOL (where you completed Elementary Level education / Grade 6)

Elementary School Name (Do not abbreviate) Month/Year of Completion

SD KRISTEN IMANUEL June/2016
Address (City/Town or Province) Region
Jl. Anggrek no 54, Situbondo, Jawa Timur Java Island

Month/Year of Completion
Are you a passer of Philippine Educational Placement Test (PEPT) for Elementary Level? No Yes

Month/Year of Completion
Are you a passer of Accreditation and Equivalency (A&E) Test for Elementary Level? No Yes

Name of Community Learning Center (Do not abbreviate) Address (City/Town or Province)

7. JUNIOR HIGH SCHOOL (JHS) (where you completed/are completing JHS / Grade 9)

JHS Name (Do not abbreviate) Month/Year of Completion

SMP KRISTEN IMANUEL May/2019
Address (City/Town or Province) Region
Jl. Anggrek no 54, Situbondo, Jawa Timur Java Island

Month/Year of Completion
Are you a passer of Philippine Educational Placement Test (PEPT) for JHS Level? No Yes

Month/Year of Completion
Are you a passer of Accreditation and Equivalency (A&E) Test for JHS Level? No Yes

Name of Community Learning Center (Do not abbreviate) Address (City/Town or Province)

8. SENIOR HIGH SCHOOL (SHS) APPLIED FOR: Choose from the list of schools offering SHS (up to two choices allowed). Do not indicate the same SHS twice.
Make sure that track (Academics, TVL, Sports, Arts and Design), and specialization choices are offered in the SHS indicated. Write NONE on the blank if you
do not have other choices of SHS/track/strand/specialization.

Name of First Choice SHS (Do not abbreviate)

SMA NEGERI 1 SITUBONDO
Address (City/Town or Province)
Jl. Pb. Sudirman no 5a, Situbondo
First Choice SMAN 1 SITUBONDO Second Choice NONE
Track: Academics (MIPA) Track:

Specializations: Specializations:
1. SKS system 1.

2. Near home (±2km) 2.

3. Favorite school in Situbondo 3.

4. Has so many extracurricular 4.

THIS REGISTRATION FORM IS NOT FOR SALE AND MAY BE REPRODUCED

 Name of Second Choice SHS (Do not abbreviate)
SMA NEGERI 2 SITUBONDO
Address (City/Town or Province)
Jl. Anggrek no 1, Situbondo
First Choice SMA N 2 SITU BON DO Second Choice NO NE
Track: Academics (MIPA) Track:

Specializations: Specializations:
sys
te (20
1. SKS m 19) 1.

2. 2.

3. 3.

4. 4.

9. PERMANENT HOME ADDRESS

House Number and Street J L J AWA N O 8

Subdivision/Barangay P A N J I
Town/City S I T U B O N D O
Postal/Zip Code
Province J AWA T I MU R 6 8 3 2 2

10. FAMILY INFORMATION

Total Child 1
Father Name S T E V I E W I B I S O N O Age
5 5
Job
E N T R E P R E N E U R
Mother Name L I L I S S U L I S T Y O WA T I Age
5 0
Job HO U S E W I F E
Family Card number
3 5 1 2 0 8 1 5 0 4 0 8 0 0 36
11. CONTACT INFORMATION

Telephone Number 0 3 3 8 6 7 2 3 6 2 Cellphone Number 0 8 2 3 3 1 6 3 7 0 2 2

2

E-mail Address O B E D W 3 2 @ G M A I L . C O M

12. STUDENT INFORMATION

NATIONAL EXAM CARD (JHS) 2 1 9 0 5 3 2 0 0 1 8 0 0 1 5 2
NIS (JHS) 7 4 1
NATIONAL NIS (JHS) 0 0 4 3 6 5 5 1 0 9
SPECIAL NEEDS
DEAF, MENTAL PROBLEM,

THIS REGISTRATION FORM IS NOT FOR SALE AND MAY BE REPRODUCED

I affirm that:
(1) I have read the information contained in DepEd Order No. ___, s. 2015 and understood all the instructions in connection with my registration;
(2) I have been made aware of the SHS tracks and the importance of choosing the right career path through the Career Guidance Program;
(3) The preferences supplied in this slip are a result of a well-informed decision making as discussed with my parent(s)/guardian; and
(4) I will abide by the DepEd rules and policies in relation to the SHS program.

Furthermore, I understand that all information I provide in this form may be used by the Department of Education and I consent to such with the assurance that my personal
details will be kept confidential.

OBED WIBISONO LILIS SULISTYOWATI

Signature over Printed Name of the Student Signature over Printed Name of the Parent/Guardian
__________________ __________________
Date Date

REMINDERS:

THIS REGISTRATION FORM IS NOT FOR SALE AND MAY BE REPRODUCED