To be filled up by DSHS Personnel Department of Education

Application No.____________ Division of Dumaguete City Please staple a

Room Assignment: _________
REGIONAL SCIENCE HIGH SCHOOL VII recent 1 X 1
Ramon Teves Pastor Memorial-Dumaguete Science High School picture and write
Dumaguete City your name at the
back.

APPLICATION FORM FOR GRADE 7 ENTRANCE EXAMINATION

SY 2017-2018
Instructions:

1. All signatures shall be in blue ink. 4. Submit this application on or before the due date.
2. Corrections have to be countersigned. 5. This form may be reproduced.
3. Fill in all required information. 6. Deadline for submission of requirements is on April 11, 2017.

A. PERSONAL INFORMATION

1. Name of Applicant

Last Name First Name Middle Name Male/Female

2. Father's Name Profession/Occupation 3. Mother's Maiden Name Profession/Occupation

4. Contact Home Address 5. Contact No. (Cellphone/Landline of Parents)

B. SCHOOL BACKGROUND

1. Elementary School (where pupil is graduating/graduated) 2. Elementary School’s Mailing Address

_____________________________________________________ _____________________________________________________

3. Date Established 4. School’s Tel. No. 5. Email Address

______________ ____________ _____________________________________________________

6. Elementary School Type (please check) 7. Type of Elementary School Curriculum (please check)
( ) public ( ) private ( ) General ( ) Science-Oriented
( ) SPED ( ) Others, please specify

8. Rank in graduating class: __________ 9. Total No. of Expected Graduates: ___________

10. Expected Date of Graduation: __________

C. CERTIFICATION/RECOMMENDATION

I certify that ____________________________________________ belongs to the top 10 or upper 10% of the graduating
class of SY _______________. (This requirement is waived for pupil graduates of special science and/or SPED fast learner classes.)
He/she is recommended to take the RSHS Examination.

Name and Signature of Adviser Name and Signature of the School Principal

Please cut here.

Name of Applicant: _________________________________________________________ Room Assignment: _____________

REMINDERS

1. Examination starts at 8:00AM. Please report to the examination April 17, 2017 First Phase
center at least 30 minutes before testing time. Mental Ability & Aptitude Test
2. Bring ball pen, pencil, and a clean sheet of paper.
3. All examinees are prohibited from bringing cellphones and April 19, 2017 Second Phase
calculators inside the testing room. Proficiency Test in English, Science & Math
4. Always remember testing dates. (See back portion) for 2nd phase qualifiers only
5. Examination time runs for about 3 hours.
April 21, 2017 Third Phase
6. Please present this room assignment slip to the proctor in your Interview
assigned examination room. for 3rd phase qualifiers only

REQUIREMENTS FOR SUBMISSION

□ Photocopy of Form 138 (Report Card) certified by the School Head
*Final Grade in English VI, Science VI, and Math VI at least 85% and no grade lower than 80% in any subject in any
grading period in Grade VI

This form is NOT FOR SALE. This form may be reproduced for distribution.
□ Fully accomplished application form with 1x1 picture

This form is NOT FOR SALE. This form may be reproduced for distribution.