UPCAT Form 1 (Rev.3-2012) VALID ONLY FOR UPCAT 2013 TO BE FILLED OUT ONLY BY PERSONNEL AUTHORIZED TO RECEIVE AND/OR PROCESS APPLICATIONS. Document Inventory Number UNIVERSITY OF THE PHILIPPINES UPCAT APPLICATION FOR FRESHMAN ADMISSION FIRST SEMESTER AY 2013-2014 TO THE STUDENT AND PARENTS/GUARDIAN: Carefully read the GENERAL INFORMATION BULLETIN ON FRESHMAN ADMISSION before filling out this application form. Print legibly all information required. Place X marks in appropriate boxes. Only accomplished application forms, UPCAT Form 1 and UPCAT Form 2 (Secondary School 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 2316 Testing Fee F2 OTR GP/GR Affidavit PEPT GCSE/GCE Passport NBCR/ICR Remarks: Received by Exemption Evaluator TP Checker 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. LAST FIRST MIDDLE Staple here Staple a recent 2" X 2" photograph (taken within the last six months) in this box. - 2. 3. 4. 5. 6. SEX 1 Male 2 Female DATE OF BIRTH (Month, Day, Year) PLACE OF BIRTH (City/Town, Province) Be sure to print your name at the back of the photo. Yes (Specify) MEMBER OF CULTURAL MINORITY GROUP? 2 CITIZENSHIP 1 2 No 1 Staple here Filipino (If born abroad please submit a photocopy of a valid Philippine passport or a BOI Identification Certificate) Foreign (Specify) 3 Dual (Specify) 7. HIGH SCHOOL (where you completed/are completing secondary level education): High School Name (Do not abbreviate) Month/Year of Completion Address (City/Town,Province) Region High School Name & Address Have you attended secondary level education anywhere else? 2 Year of Graduation from Elementary Level No 1 Yes (Where) Year 8. UP CAMPUS APPLIED FOR: Choose from among the following (up to two choices allowed) 1 UP Baguio, Baguio City 2 UP Cebu, Cebu City 3 UP Extension Program Pampanga, Clarkfield, Pampanga 4 UP Diliman, Quezon City 5 UP Visayas, Iloilo City 6 UP Los Baños, Laguna 7 UP Manila, Manila 8 UP Tacloban College, Tacloban City 9 UP Mindanao, Davao 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 1st choice INTENDED COURSE (See list of Undergraduate Degree Programs) COURSE CODE { { 1st choice 2nd choice 1st choice 2nd choice No 1 Yes (Only those indicating their interest will be considered for this program) 2nd choice 9. Are you also interested in entering an accelerated program leading to Medicine? 2 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 Norte 0122 Dagupan City 0126 San Fernando City, La Union 0125 Urdaneta City 0129 Vigan City REGION 2 (CAGAYAN VALLEY) Aparri,Cagayan 0202 0201 Basco, Batanes 0206 Bayombong, Nueva Vizcaya 0207 Diffun, Quirino 0208 Ilagan, Isabela 0223 Tuguegarao City REGION 3 (CENTRAL LUZON) 0327 Balanga City 0307 Baler, Aurora 0322 Cabanatuan City 0332 Malolos City 0302 Meycauayan, Bulacan 0323 Olongapo City 0326 Tarlac City 0321 UPEPP, Clarkfield, Pampanga REGION 4-A (CALABARZON) 0429 Antipolo City 0403 Bacoor, Cavite 0421 Batangas City 0403 Imus, Cavite 0424 Lucena City 0428 Trece Martires City 0404 UP Los Baños, Laguna REGION 4-B (MIMAROPA) 1701 Boac, Marinduque Calapan City 1721 1704 Cuyo, Palawan 1705 Odiongan, Romblon 1722 Puerto Princesa City 1702 San Jose, Occidental Mindoro REGION 5 (BICOL) 0502 Daet, Camarines Norte 0522 Legazpi City 0525 Masbate City 0523 Naga City 0526 Sorsogon City 0504 Virac, Catanduanes REGION 6 (WESTERN VISAYAS) 0621 Bacolod City 0601 Kalibo, Aklan 0626 Roxas City 0602 San Jose, Antique 0624 UP Visayas, Iloilo City REGION 7 (CENTRAL VISAYAS) Dumaguete City 0725 0704 Larena, Siquijor 0728 Tagbilaran City 0723 UP Cebu, Cebu City REGION 8 (EASTERN VISAYAS) 0804 Borongan, Eastern Samar Catarman, Northern Samar 0805 0806 Catbalogan, Western Samar 0824 Maasin City 0801 Naval, Biliran 0822 Ormoc City 0823 UP Tacloban College, Tacloban City REGION 9 (ZAMBOANGA PENINSULA) 0922 Dipolog City 0923 Pagadian City 0924 Zamboanga City REGION 10 (NORTHERN MINDANAO) 1022 Cagayan de Oro City 1030 Iligan City 1028 Malaybalay City 1004 Mambajao, Camiguin 1024 Oroquieta City REGION 11 (DAVAO) 1121 UP Mindanao, Davao City 1124 Digos City 1123 Tagum City REGION 12 (SOCCSKSARGEN) 1228 Cotabato City Gen. Santos City 1225 1204 Kabacan, North Cotabato Koronadal City 1226 1227 Tacurong City REGION 13 (CARAGA) 1321 Butuan City Prosperidad, Agusan del Sur 1302 1322 Surigao City 1304 Tandag, Surigao del Sur REGION 14 (CAR) 1403 Banaue, Ifugao 1401 Bangued, Abra 1405 Bontoc, Mt. Province 1407 Tabuk, Kalinga 1421 UP Baguio, Baguio City NATIONAL CAPITAL REGION 1624 UP Diliman, Quezon City 1622 UP Manila, Manila THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED. NAME Father Mother (Maiden Name) MARITAL CITIZENSHIP STATUS HIGHEST EDUCATIONAL ATTAINMENT PRESENT OCCUPATION EMPLOYER (Do not leave blank) ANNUAL GROSS INCOME (in Phil. Subtotal 15. . . attach Certification of Disability and contact the Director. . indicate the educational level which the household member actually completed (e. . Town / City . college or university. . . . (2) I have read all information contained in the General Information Bulletin on Freshman Admission Academic Year 2013-2014 and agree to abide by the University rules and policies on student fees including tuition. . . . . (e) erasures and corrections have been initialed by the principal. District . . . . . 4.) In active service On leave with pay On leave without pay On secondment 12. 16. . SOCIO-ECONOMIC DATA. . . I also understand that no results for my application may be released until all requirements are satisfied. . . . Furnish all the required information on each family member listed. .) 13. . . . complete. (f) school dry seal (if any) is affixed. . . B. . . .). Third Year High School. . . . . . . Province . . . . (2) All the information supplied in this application form are true. Write down mother's maiden name. Telephone No (1) E-mail Address Telephone No (2) 14. . . Cellphone Number . . . . ARE YOU A CHILD OF A UP FACULTY OR EMPLOYEE? 2 No 1 Yes Name of parent employed by UP Official Designation College/Unit where employed A. . . . . . 2. . . . Print permanent home address and telephone number. I certify that: (1) the information which my son/daughter/dependent has provided in this application form is true. ADDRESS AND TELEPHONE NUMBER. . . . . PERMANENT HOME ADDRESS Number and Street . I share with my son/ daughter/dependent the responsibility for the veracity and completeness of the information supplied herein. Write DECEASED after name of deceased family members.. and accurate.. . . Tenure Temporary Permanent Contractual Casual C. . . . please attach a photocopy of your FAMILY'S 2011 income tax returns or BIR certification/s. Postal/Zip Code . . 3. . . . EACH PHOTOGRAPH SHOULD HAVE YOUR PRINTED NAME AT THE BACK. . . SIGNATURE OF STUDENT DATE REMINDERS: SIGNATURE OF PARENT/GUARDIAN DATE No results may be released pending submission of all requirements stipulated in UPCAT Form 2 (Secondary School Record). lecturer.E. . and (4) I will abide by the University rules and policies on test administration and on student fees including tuition. Have you applied/are you planning to apply to other schools? 2 Have you ever attended any UPCAT review classes? 2 No 1 No 1 Yes Yes What are these schools? Where/With what center? I affirm that: (1) I have read all the information contained in the General Information Bulletin on Freshman Admission for Academic Year 2013-2014 and understood all the instructions in connection with my application for the UPCAT. Category Full-time Part-time (e. .. scholarships. . . . . (c) the number of units for each subject is indicated. 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. Under the column "Highest Educational Attainment". . . . . (g) your signature is on the space indicated. I am aware that any or all the information furnished in this application may be checked against the original documents and that withholding information or giving false information will disqualify me from admission/will be a basis for dismissal.S. . . complete. High School Graduate. (b) failing grades (if any) are also included. . . . . and accurate. . . .000.g. Barangay. . . . .D. . scholarships. and financial assistance programs. 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. peso) Legal Guardian Subtotal BROTHERS AND SISTERS (Only those who are single): 1. . . Specifically. . . and (h) a Certified True Copy of the certificate of Government Recognition or Government Permit of each private school attended is submitted. . check that: (a) final grades for all subjects taken are complete and accurate. . . . . I recognize that in signing this application form. . . . REMEMBER TO CLIP ON YOUR APPLICATION FORM TWO ADDITIONAL IDENTICAL RECENT PHOTOGRAPHS FOR YOUR TEST PERMIT. . Second Year College. .) With compensation Without compensation B. . Grade II. . . . NOTE: If your annual family gross income is equal to or less than P 100. . Form 2 must be accomplished accurately and completely by the Office of the Principal/School Head. Subdivision / Village. if admitted. . . Status (Place an X in only one box. etc. (d) the principal's signature is across the photograph and at the bottom of both pages of the form. . . or Ph.g.11. and financial assistance programs. . (3) I have not taken the UPCAT previously and that I am not taking nor have I taken any college subject in any school. .