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Form 1 of Upcat for First Semester 2010 2011 document sample
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UPCAT Form 1 (Rev. 2-2010)
TO BE FILLED OUT ONLY BY PERSONNEL AUTHORIZED TO RECEIVE
AND/OR PROCESS APPLICATIONS.
Document Inventory Number
Testing Fee:
UNIVERSITY OF THE PHILIPPINES P450 US$50 US$100
UPCAT APPLICATION FOR FRESHMAN ADMISSION Exempted:
FIRST SEMESTER AY 2011-2012 TOP 10 INCOME
Deficiency/cies:
TO THE STUDENT AND PARENTS/GUARDIAN: List of Top 10 across all curricular programs/annexes
BIR Certificate / ITR / Cert of Compensation 2316
Carefully read the GENERAL INFORMATION BULLETIN ON FRESHMAN ADMISSION Testing Fee P__________
before filling out this application form. F2 OTR GP/GR Affidavit
PEPT GCSE/GCE Passport NBCR/ICR
Print legibly all information required. Place X marks in appropriate boxes. Only
accomplished application forms, UPCAT Form 1 and UPCAT Form 2 (Secondary
Received by TP Checker
School Record) will be processed.
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
Staple here
FIRST
MIDDLE Staple a recent 2" X 2" photograph
(taken within the last six months) in
2. SEX 1 Male 2 Female this box.
3. DATE OF BIRTH (Month, Day, Year) - - Be sure to print your name at the back
of the photo.
4. PLACE OF BIRTH (City/Town, Province)
5. MEMBER OF CULTURAL MINORITY GROUP? 2 No 1 Yes (Specify) Staple here
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)
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 No 1 Yes (Where)
Year of Graduation from Elementary Level
8. UP CAMPUS APPLIED FOR: Choose from among the following (up to two choices allowed)
1 UP Baguio, Baguio City 4 UP Diliman, Quezon City 7 UP Manila, Manila
2 UP Cebu College, Cebu City 5 UP Visayas, Iloilo City 8 UP Tacloban College, Tacloban City
3 UP Extension Program Pampanga, Clarkfield, Pampanga 6 UP Los Baños, Laguna 9 UP Mindanao, Davao City
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 choice
1st choice
{ 2nd choice
1st choice
2nd 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) REGION 4-A (CALABARZON) 0602 San Jose, Antique REGION 11 (DAVAO)
0103 Batac, Ilocos Norte 0421 Batangas City 0624 UP Visayas, Iloilo City 1121 UP Mindanao, Davao City
0122 Dagupan City 0403 Imus, Cavite REGION 7 (CENTRAL VISAYAS) 1124 Digos City
0126 San Fernando City, La Union 0424 Lucena City 0725 Dumaguete City 1123 Tagum City
0125 Urdaneta City 0404 UP Los Baños, Laguna 0704 Larena, Siquijor REGION 12 (SOCCSKSARGEN)
0129 Vigan City REGION 4-B (MIMAROPA) 0728 Tagbilaran City 1228 Cotabato City
REGION 2 (CAGAYAN VALLEY) 1701 Boac, Marinduque 0723 UP Cebu College, Cebu City 1225 Gen. Santos City
0202 Aparri,Cagayan 1721 Calapan City REGION 8 (EASTERN VISAYAS) 1204 Kabacan, North Cotabato
0201 Basco, Batanes 1704 Cuyo, Palawan 0804 Borongan, Eastern Samar 1226 Koronadal City
0206 Bayombong, Nueva Vizcaya 1705 Odiongan, Romblon 0805 Catarman, Northern Samar 1227 Tacurong City
1722 Puerto Princesa City 0806 Catbalogan, Western Samar REGION 13 (CARAGA)
0207 Diffun, Quirino
1702 San Jose, Occidental Mindoro 0824 Maasin City 1321 Butuan City
0208 Ilagan, Isabela
REGION 5 (BICOL) 0823 UP Tacloban College, Tacloban City 1302 Prosperidad, Agusan del Sur
0223 Tuguegarao City
0502 Daet, Camarines Norte REGION 9 (ZAMBOANGA PENINSULA) 1322 Surigao City
REGION 3 (CENTRAL LUZON) 0522 Legazpi City 0922 Dipolog City 1304 Tandag, Surigao del Sur
0327 Balanga City 0525 Masbate City 0923 Pagadian City REGION 14 (CAR)
0307 Baler, Aurora 0523 Naga City 0924 Zamboanga City 1403 Banaue, Ifugao
0322 Cabanatuan City 0526 Sorsogon City REGION 10 (NORTHERN MINDANAO) 1401 Bangued, Abra
0332 Malolos City 0504 Virac, Catanduanes 1022 Cagayan de Oro City 1405 Bontoc, Mt. Province
0302 Meycauayan, Bulacan REGION 6 (WESTERN VISAYAS) 1030 Iligan City 1407 Tabuk, Kalinga
0323 Olongapo City 0621 Bacolod City 1028 Malaybalay City 1421 UP Baguio, Baguio City
0326 Tarlac City 0601 Kalibo, Aklan 1004 Mambajao, Camiguin NATIONAL CAPITAL REGION
0321 UPEPP, Clarkfield, Pampanga 0626 Roxas City 1024 Oroquieta City 1624 UP Diliman, Quezon City
THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED.
11. 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. 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 Asst. Director for Test Administration)
13. ADDRESS AND TELEPHONE NUMBER. Print permanent home address and telephone number.
PERMANENT HOME ADDRESS
Number and Street . . . . . . . . . . . . . . . . . . . .
Subdivision / Village, Barangay, District . . .
Town / City . . . . . . . . . . . . . . . . . . . . . . . . . . .
Province . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone No (1) Telephone No (2)
Postal/Zip Code . . . . . . . . . . . . . . . . . . . . . . .
E-mail Address
Cellphone Number . . . . . . . . . . . . . . . . . . . . .
14. SOCIO-ECONOMIC DATA. Furnish all the required information on each family member listed. Write DECEASED after name of deceased family members. Write down mother's maiden name. Under
the column "Highest Educational Attainment", indicate the educational level which the household member actually completed (e.g., Grade II, Third Year High School, High School Graduate, Second Year College,
B.S.E., or Ph.D.).
NOTE: If your annual family gross income is equal to or less than P 100,000, please attach a photocopy of your FAMILY'S 2009 income tax returns or BIR certification/s.
HIGHEST (Do not leave blank)
MARITAL PRESENT ANNUAL
EDUCATIONAL EMPLOYER
NAME CITIZENSHIP OCCUPATION GROSS INCOME
STATUS ATTAINMENT (in Phil. peso)
Father
Mother
(Maiden Name)
Legal Guardian
Subtotal
BROTHERS AND SISTERS (Only those who are single):
1.
2.
3.
4.
Subtotal
15. Have you applied/are you planning to apply to other schools? 2 No 1 Yes What are these schools?
16. Have you ever attended any UPCAT review classes? 2 No 1 Yes Where/With what center?
I affirm that: I certify that:
(1) I have read all the information contained in the General Information Bulletin on Freshman (1) the information which my son/daughter/dependent has furnished
Admission for Academic Year 2011-2012 and understood all the instructions in connection in this application form is true, complete, and accurate.
with my application for the UPCAT; (2) I have read all information contained in the General Information
(2) All the information supplied in this application form are true, complete, and accurate; Bulletin on Freshman Admission Academic Year 2011-2012 and
(3) I have not taken the UPCAT previously and that I am not taking nor have I taken any college agree to abide by the University rules and policies on student fees
subject in any school, college or university; and including tuition, scholarships, and financial assistance programs.
(4) I will abide by the University rules and policies on test administration and on student fees
I recognize that in signing this application form, I share with my son/
including tuition, scholarships, and financial assistance programs.
daughter/dependent the responsibility for the veracity and completeness
I am aware that any or all the information furnished in this application may be checked against the of the information supplied herein.
original documents and that withholding information or giving false information will disqualify me
from admission/will be a basis for dismissal, if admitted. I also understand that no results for my
application may be released until all requirements are satisfied.
SIGNATURE OF STUDENT SIGNATURE OF PARENT/GUARDIAN
DATE DATE
REMINDERS:
No results may be released pending submission of all requirements stipulated in UPCAT Form 2 (Secondary School Record). Form 2 must be accomplished
accurately and completely by the Office of the Principal/School Head. Check specially on the following: (a) final 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 been initialed by the principal; (f) school dry seal (if any) is affixed; (g) your signature is on the space indicated;
and (h) Certified True Copy of the certificates of Government Recognition or Government Permit of each private school attended are 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.
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