Individual Inventory Record Form

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Student No. ___________________
Form 1A -GCTS
Polytechnic University of the Philippines
GUIDANCE, COUNSELING AND TESTING SERVICES
Sta. Mesa, Manila
INDIVIDUAL INVENTORY RECORD FORM
__________________________
Date
Please
clearly
PRINT
I. PERSONAL INFORMATION
Gender: ___________
Age: ____________
Name: ______________________________________________________
Civil Status: ___________________________
(Surname)
(First Name)
(Middle Name)
Date of Birth: _________________________
Course, Year and Section: _______________________________________
Place of Birth: _________________________
Height (m): _________ Weight: __________ Complexion: __________
Email Address: ________________________
City Address: _________________________________________________
Telephone No.: ________________________
Provincial Address: ____________________________________________
Mobile No.: ___________________________
High School General Average: ________ Religion: __________________
If working, please indicate the name and address of employer: ____________________________________________
Person to be contacted in case of accident or serious illness: _______________________________________________
Address: ________________________________ Relationship: _____________ Contact Number: ______________
II. EDUCATIONAL BACKGROUND
HONORS
PUBLIC
DATES OF
RECEIVED/
LEVEL
SCHOOL GRADUATED
SCHOOL ADDRESS
/PRIVATE
ATTENDANCE
SPECIAL
AWARDS
Pre-elementary
Elementary
High School
Vocational
College if any
Nature of Schooling:
[ ]
Continuous
[ ] Interrupted, Why? _____________________________________
III. HOME AND FAMILY BACKGROUND
Name of Father: ____________________________________________ Age: _____ [ ] Living [ ] Deceased
Educational Attainment:______________________________________ Occupation: ______________________
Name of Employer: __________________________________ Address of Employer:______________________
Name of Mother: ____________________________________________ Age: _____ [ ] Living [ ] Deceased
Educational Attainment: ________________________________________ Occupation: __________________
Name of Employer: __________________________________ Address of Employer: _____________________
Name of Guardian: __________________________________________ Age: _____ Relation:______________
Educational Attainment: ________________________________________ Occupation: __________________
Name of Employer: __________________________________ Address of Employer:______________________
Parents’ Marital Relationship: (Please Check)
[ ] Single Parent
[ ] Married and staying together
[ ] Married but Separated
[ ] Not Married but Living Together
[ ] Other’s (please specify) _____________________
Number of children in the family including yourself:____ Number of Brother/s: ____ Number of Sister/s: ____
st
nd
Number of brother/s or sister/s gainfully employed? _______ Ordinal Position (1
child, 2
child etc. )_______
Is your brother/sister who is gainfully employed providing support to your: (Please Check)
[ ] family?
[ ] your studies?
[ ] his/her own family?
Who finances your schooling? [ ] Parents
[ ] Spouse
[ ] Relatives
[ ] Brother/Sister
[ ] Scholarship
[ ] Self-supporting/working student

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