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Unniivveerrssiittyy P
Poolliiccee FFoorrccee
Office of the Vice Chancellor for Community Affairs
UNIVERSITY OF THE PHILIPPINES LOS BAOS
College, Laguna 4031 Philippines
Tel. Nos. (049)536-2243/2419

______________
Date

Please attached
2 x2
picture

NAME:____________________________________________________________________________
(Surname)

(Given Name)

(Middle Name)

HOME ADDRESS:____________________________________________Tel. No.________________

OFFICE ADDRESS:__________________________________________Tel. No._________________
BIRTH PLACE:___________________________________________BIRTH DATE:______________
PRESENT OCCUPATION:_________________________________ CITIZENSHIP:______________
CIVIL STATUS:_____________________________ NAME OF SPOUSE:______________________
DRIVERs LICENSE NO.________________________________ ISSUED AT:__________________
ISSUED ON:________________________________EXPIRY DATE:_______________
TYPE/MODEL of VEHICLE:______________________________YEAR MODEL:_______________
MOTOR NO.___________________________________________ CHASSIS NO.________________
PLATE NO._____________________________________________ COLOR:____________________
PREVIOUS STICKER: (Year)_______________________________ STICKER NO.______________
I HEREBY CERTIFY THAT THE ABOVE INFORMATION ARE TRUE AND CORRECT:
I undertake to exhibit my drivers license voluntarily upon demand of the guard at the UPLB
Entrances and likewise shall require my driver to show his drivers license and comply with all my
commitments in the application.
I further commit that I personally and my driver will abide by all UPLB Rules and
Regulations pertaining to the operation of the vehicles, speed limit and parking while inside the UPLB
campus and if found in violation thereof, I agree to have myself or my driver apprehended or cited in
accordance with law. I also undertake to destroy UPLB decal upon sale/transfer of my vehicle to
anybody who has no privilege to enter UPLB entrances for violation of any of the conditions.

_________________________
(Applicants Signature)

RECOMMENDING AUTHORITIES:
____________________________________

APPROVED:

____________________________________

___________________________________

Requirements:
1.
2.
3.

Original & photocopy of Vehicles Certificate of Registration.

Original & photocopy of current Official Receipt of registration.
Other pertinent supporting papers (For PUJ: LTFRB Franchise/Decision, Insurance and
Drivers ID).