7/28/2019 Upcat Form 1 (Pds2014)

1/2

7. HIGH SCHOOL (where you completed/are completing secondary level education):

Have you attended secondary level education anywhere else? 2 No 1 Yes (Where)

Year of Graduation from Elementary Level

High School Name (Do not abbreviate) Month/Yearof Completion

Address (City/Town,Province) Region

High School Name & Address Year

THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED.

1. NAME OF STUDENT: Print or type your full name in the following sequence: LAST NAME, FIRST NAME, MIDDLE NAME. Place one letter in each box. Leave one box blank between names.

2. SEX 1 Male 2 Female

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

4. PLACE OF BIRTH (City/Town, Province)

5. MEMBER OF CULTURAL MINORITY GROUP? 2 No 1 Yes (Specify)

6. CITIZENSHIP 1 Filipino (If born abroad please submit a photocopy of a valid Philippine passport or a BOI Identification Certificate)

2 Foreign (Specify) 3 Dual (Specify)

Staple here

Staple a recent 2" X 2" photograph

(taken within the last six months) in this

box.

Be sure to print your name at the back

of the photo.

Staple here

LAST

FIRST

MIDDLE

UPCAT Form 1 (Rev. 3-2013)

UNIVERSITY OF THE PHILIPPINES

UPCAT APPLICATION FOR FRESHMAN ADMISSIONFIRST SEMESTER AY 2014-2015

TO THE STUDENT AND PARENTS/GUARDIAN:

Carefully read the GENERAL INFORMATION BULLETIN ON FRESHMANADMISSION before filling out this application form.

Print legibly all information required. Place X marks in appropriate boxes. Onlyaccomplished application forms, UPCAT Form 1 and UPCAT Form 2 (SecondarySchool Record) will be processed.

Testing Fee:

P450 US$50 US$100

Exempted:

TOP 10 INCOME

Deficiency/cies:

List of Top 10 across all curricular programs/annexes

BIR Certificate / ITR / Cert of Compensation 2316Testing FeeF2 OTR GP/GR AffidavitPEPT GCSE/GCE Passport NBCR/ICR

Remarks:

{

{

TO BE FILLED OUT ONLY BY PERSONNEL AUTHORIZED TO RECEIVE

AND/OR PROCESS APPLICATIONS.

Document Inventory Number

Received by Exemption Evaluator TP Checker

VALID ONLY FOR UPCAT 2014

8. UP CAMPUS APPLIED FOR: Choose from among the following (up to two choices allowed)

1 UP Baguio, Baguio City 3 UP Extension Program Pampanga, Clarkfield, Pampanga 5 UP Visayas, Iloilo City 7 UP Manila, Manila 9 UP Mindanao, Davao City2 UP Cebu, Cebu City 4 UP Diliman, Quezon City 6 UP Los Baos, Laguna 8 UP Tacloban College, Tacloban City 10 UP Open University

Do not indicate the same campus twice. Make sure that course choices are offered in the campus indicated. Write NONE on the blank if you do not have other choices of campus/course.Countersign all erasures and corrections made. Do not indicate INTARMED or Medicine in any of the blanks for Intended Course. Please refer to question No. 9 below.

UP CAMPUS INTENDED COURSE (See list of Undergraduate Degree Programs) COURSE CODE

1st choice1st choice

2nd choice

2nd choice

1st choice

2nd choice

9. Are you also interested in entering an accelerated program leading to Medicine? 2 No 1 Yes (Only those indicating their interest will be considered for this program)

10. UPCAT TEST CENTERS (by Region). Mark the UPCAT Test Center nearest your school. (Mark only one.)

NOTE: Whenever possible, applicants will be issued Test Permits for a testing center in their respective provinces.

REGION 1 (ILOCOS)0103 Batac, Ilocos Norte0122 Dagupan City0126 San Fernando City, La Union0125 Urdaneta City0129 Vigan City

REGION 2 (CAGAYAN VALLEY)0202 Aparri,Cagayan0201 Basco, Batanes0206 Bayombong, Nueva Vizcaya0207 Diffun, Quirino0208 I lagan, Isabela0223 Tuguegarao CityREGION 3 (CENTRAL LUZON)0399 Angeles City0327 Balanga City0307 Baler, Aurora0322 Cabanatuan City0332 Malolos City0302 Meycauayan, Bulacan0323 Olongapo Cit y0326 Tarlac City0321 UPEPP, Clarkfield, PampangaREGION 4-A (CALABARZON)0429 Antipolo City

0499 Bacoor, Cavite0421 Batangas City0403 Imus, Cavite0424 Lucena City0428 Trece Mar ti res Ci ty0404 UP Los Baos, Laguna

REGION 4-B (MIMAROPA)1701 Boac, Mar induque1721 Calapan City1704 Cuyo, Palawan1705 Odiongan, Romblon1722 Puerto Princesa City1702 San Jose, Occidental MindoroREGION 5 (BICOL)0502 Daet, Camarines Norte0522 Legazpi City0525 Masbate City0523 Naga City0526 Sorsogon City0504 Vi rac, CatanduanesREGION 6 (WESTERN VISAYAS)0621 Bacolod City0601 Kalibo, Aklan0626 Roxas City0602 San Jose, Antique

REGION 11 (DAVAO)1121 UP Mindanao, Davao City

1124 Digos City

1123 Tagum CityREGION 12 (SOCCSKSARGEN)

1228 Cotabato City

1225 Gen. Santos City1204 Kabacan, North Cotabato

1226 Koronadal City

1227 Tacurong Cit yREGION 13 (CARAGA)

1321 Butuan City

1302 Prosperidad, Agusan del Sur

1322 Surigao City

1304 Tandag, Surigao del SurREGION 14 (CAR)

1403 Banaue, If ugao

1401 Bangued, Abra

1405 Bontoc, Mt . Prov ince

1407 Tabuk, Kalinga

1421 UP Baguio, Baguio CityNATIONAL CAPITAL REGION

1624 UP Dil iman, Quezon City

1622 UP Mani la , Mani la

0624 UP Visayas, Iloi lo CityREGION 7 (CENTRAL VISAYAS)

0725 Dumaguete City

0704 Larena, Siquijor

0728 Tagbilaran City

0723 UP Cebu, Cebu City

REGION 8 (EASTERN VISAYAS)0804 Borongan, Eastern Samar

0805 Catarman, Northern Samar

0806 Catbalogan, Western Samar

0824 Maasin City

0801 Naval, Biliran

0822 Ormoc City

0823 UP Tacloban College, Tacloban CityREGION 9 (ZAMBOANGA PENINSULA)

0922 Dipolog City

0923 Pagadian City

0924 Zamboanga CityREGION 10 (NORTHERN MINDANAO)

1022 Cagayan de Oro City

1030 Iligan City

1028 Malaybalay City

1004 Mambajao, Camiguin

1024 Oroquieta City

7/28/2019 Upcat Form 1 (Pds2014)

2/2

11. ARE YOU A CHILD OF A UP FACULTY OR EMPLOYEE?

2 No 1 Yes

A. Category B. Tenure C. Status (Place an X in only one box.)

Full-time Temporary In active service

Part-time (e.g., lecturer, etc.) Permanent On leave with pay

With compensation Contractual On leave without pay

Without compensation Casual On secondment

12. Do you have any PHYSICAL DISABILITY or CONDITION that requires special attention or would make it difficult for you to take a regular test?

2 No 1 Yes (specify)

(for PWDs taking the exam in Diliman, attach Certification of Disability and contact the Director.)

13. PERMANENT HOME ADDRESS

Number and Street . . . . . . . . . . . . . . . . . . . .

Subdivision / Village, Barangay, District . . .

Town / City . . . . . . . . . . . . . . . . . . . . . . . . . . .

Province . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Postal/Zip Code

14. CONTACT INFORMATION

Telephone Number . . . . . . . . . . . . . . . . . . . .

Cellphone Number

E-mail Address . . . . . . . . . . . . . . . . . . . . . . .

15. SOCIO-ECONOMIC DATA.Furnish ALLthe required information for each household member listed. For purposes of this section, HOUSEHOLD is defined asa social unit consisting of a person living alone ora group of persons who sleep in the same housing unit and have a common arrangement in the preparation and consumption of food. Also included are those who may not be with the group but are blood related and

contribute regularly to household finances, e.g. OFW parent.NOTE: if the requested information is not applicable, plese leave the space blank.

(1) For each of theOther Household Members, indicate the member's relationship to the student (e.g. grandmother, aunt, uncle, etc.)(2) Write DECEASED after name of deceased parent. Write down mother's maiden name.(5) Indicate the highest educational level which each household member actually completed (e.g. Elementary, High School, College Undergraduate, BA, BS, MBA or PhD).(8) INCOME includes wages and salaries, income from business/farm/profession, allowances, and investment income/earnings.(9) Pension from GSIS, SSS, Provident Fund, or former employer.(10) Financial assistance includes cash and other forms of financial support from any domestic or foreign source (e.g. relatives, friends, NGOs, LGUs), including scholarships and educational plans.

Household Civil Highest PresentMembers Name Cit izenship Status Educat ional Occupation Employer Income Pension Financial Total

Attainment Assistance (11)(1) (2) (3) (4) (5) (6) (7)

(8) (9) (10) =(8)+(9)+(10)

Applicant

Father

Mother

Sub-Total (a)

Brothers and Sisters

Sub-Total (b)

Other Household Members (those contributing to household finances on a regular basis)

Sub-Total (c)

Name of parent employed by UP Official Designation College/Unit where employed

SOURCES OF FUNDS in the YEAR 2012 (in Pesos)

I certify that:(1) the information which my son/daughter/dependent has

provided in this application form is true, complete,and accurate.

(2) I have read all information contained in the GeneralInformation Bulletin on Freshman Admission Academic

Year 2014-2015and agree to abide by the Universityrules and policies on student fees including tuition,scholarships, and financial assistance programs.

I recognize that in signing this application form, I share withmy son/daughter/dependent the responsibility for the veracityand completeness of the information supplied herein.

SIGNATURE OF PARENT/GUARDIAN

DATE

I affirm that:(1) I have read all the information contained in the General Information Bulletin on Freshman Admission for

Academic Year 2014-2015and understood all the instructions in connection with my application for the UPCAT;(2) All the information supplied in this application form are true, complete, and accurate;(3) I have not taken the UPCAT previously and that I am not taking nor have I taken any college subject in

any school, college or university; and(4) I will abide by the University rules and policies on test administration and on student fees including

tuition, scholarships, and financial assistance programs.

I am aware that any or all the information furnished in this application may be checked against the originaldocuments and that withholding information or giving false information will disqualify me from admission/willbe a basis for dismissal, if admitted. I also understand that no results for my application may be releaseduntil all requirements are satisfied.

Furthermore, I understand that all information I provide in this form as well as during the UPCAT may be usedby the University for research and I consent to such with the assurance that my personal details will be keptsecure.

SIGNATURE OF STUDENT

DATE

REMINDERS:

No results may be released pending submission of all requirements stipulated in UPCAT Form 2 (Secondary School Record). Form 2must be accomplished accurately andcompletely by the Office of the Principal/School Head. Specifically, check that: (a) f inal grades for all subjects taken are complete and accurate; (b) failing grades (if any) are also included;(c) the number of units for each subject is indicated; (d) the principal's signature is across the photograph and at the bottom of both pages of the form; (e) erasures and corrections have beeninitialed by the principal; (f) school dry seal (if any) is affixed; (g) your signature is on the space indicated; and (h) a Certified True Copy of the certificate ofGovernment Recognition orGovernment Permit of each private school attended is submitted.

REMEMBER TO CLIP ON YOUR APPLICATION FORM TWO ADDITIONAL IDENTICAL RECENT PHOTOGRAPHS FOR YOUR TEST PERMIT. THEY SHOULD BE

IDENTICAL TO THE ONES YOU ATTACHED ON THE FRONT PAGE AND ON UPCAT FORM 2 (SECONDARY SCHOOL RECORD). DO NOT PASTE THE PHOTOGRAPHS.

EACH PHOTOGRAPH SHOULD HAVE YOUR PRINTED NAME AT THE BACK.

NOTE: If your annual family gross income is equal to or less than P 100,000, please attach a photocopy of your FAMILY'S 2012 income tax returns or BIR certification/s.