2455 Taft Avenue, Manila, Philippines 1004
To the applicant: Submission of this signed notarized document to the Admissions Center is a requirement for
conrmation of enrollment at De La Salle-College of Saint Benilde.
De La Salle-College of Saint Benilde (DLS-CSB) has the academic freedom to prescribe requirements and/or conditions
for admission and continuous enrollment of students in the College.
I, (
Surname, First Name, Middle Name
) _______________________________________________________________________________________,
(
Nationality
) ___________________________, legal age/minor, with residence at ___________________________________________________
________________________________________ after having been duly sworn in accordance with law, deposes and states that:
(Please check statement which applies to you.)
I acknowledge the authority of the College: (1) to prescribe requirements and/or conditions, rules and regulations
for admission and continuous enrollment of students; and (2) to withhold recognition to fraternities, sororities or
organizations which it considers are inimical to the mission, vision and philosophy of the College or to the peace and order
in the College.
I also understand that I shall not join any fraternity, sorority or organization not recognized by De La Salle-College of Saint
Benilde during my entire stay in the College.
I recognize and accept that my continued stay in the College is subject to my compliance with the prescribed policies,
rules and regulations on non-membership in fraternities, sororities or organizations not recognized by the College.
I understand that the College can dismiss me, if subsequently, I am found to have violated conditions and/or falsied
statements in this contract.
SUBSCRIBED AND SWORN to before me this _________________________ in _________________________
by the above student and/or parent/guardian. Aant exhibiting to me:
Name Identication Card/No. Date of Issuance or Expiration/Place of Issue
I am not a member of any fraternity, sorority or organization not recognized by De La Salle-College of Saint Benilde;
I am a member of _______________________________________________ fraternity, sorority or organization not recognized
by De La Salle-College of Saint Benilde but attached and submitted herewith is my voluntarily executed written
undertaking to renounce and/or rescind my membership from said fraternity, sorority or organization not
recognized by De La Salle-College of Saint Benilde.
De La Salle-College of Saint Benilde
Attached 2x2
Colored picture
with signature
at the back
Printed Name and Signature of Student
___________________________________________________
Date: _____________________________________________
If student is a minor
Assisted by:
___________________________________________________
Printed Name and Signature of Parent/Guardian
Doc. No. ____________
Page No.____________
Book No. ____________
Series of ___________
NOTARY PUBLIC
