UPCAT Form 1 (Rev.

3-2013)

VALID ONLY FOR UPCAT 2014

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 2014-2015
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 2. SEX 1 Male 2 Female -

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

3. DATE OF BIRTH (Month, Day, Year) 4. PLACE OF BIRTH (City/Town, Province)

5. MEMBER OF CULTURAL MINORITY GROUP? 2 6. CITIZENSHIP 1 2

No 1

Yes (Specify)

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 5 UP Visayas, Iloilo City 4 UP Diliman, Quezon City 6 UP Los Baos, Laguna 7 UP Manila, Manila 9 UP Mindanao, Davao City 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
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) 0202 Aparri,Cagayan 0201 Basco, Batanes 0206 Bayombong, Nueva Vizcaya 0207 Diffun, Quirino 0208 Ilagan, Isabela 0223 Tuguegarao City REGION 3 (CENTRAL LUZON) 0399 Angeles City 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 0499 Bacoor, Cavite 0421 Batangas City 0403 Imus, Cavite 0424 Lucena City 0428 Trece Martires City 0404 UP Los Baos, Laguna REGION 4-B (MIMAROPA) 1701 Boac, Marinduque 1721 Calapan City 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) 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 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 1225 Gen. Santos City 1204 Kabacan, North Cotabato 1226 Koronadal City 1227 Tacurong City REGION 13 (CARAGA) 1321 Butuan City 1302 Prosperidad, Agusan del Sur 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.

11.

ARE YOU A CHILD OF A UP FACULTY OR EMPLOYEE? 2 No 1 Yes Name of parent employed by UP A. Category Full-time Part-time (e.g., lecturer, etc.) With compensation Without compensation Official Designation B. Tenure Temporary Permanent Contractual Casual College/Unit where employed C. Status (Place an X in only one box.) In active service On leave with pay On leave without pay 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14. CONTACT INFORMATION Telephone Number . . . . . . . . . . . . . . . . . . . . E-mail Address . . . . . . . . . . . . . . . . . . . . . . . 15. SOCIO-ECONOMIC DATA. Furnish ALL the required information for each household member listed. For purposes of this section, HOUSEHOLD is defined as a social unit consisting of a person living alone or a 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. Household Members (1) Applicant Father Mother Sub-Total (a) Brothers and Sisters Name (2) Civil Highest Present Citizenship Status Educational Occupation Attainment (3) (4) (5) (6) Employer (7) Income (8) SOURCES OF FUNDS in the YEAR 2012 (in Pesos) Pension Financial Total Assistance (11) (9) (10) =(8)+(9)+(10) Cellphone Number Postal/Zip Code

Sub-Total (b) Other Household Members (those contributing to household finances on a regular basis)

Sub-Total (c) (1) For each of the Other 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. 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.

I affirm that: (1) I have read all the information contained in the General Information Bulletin on Freshman Admission for Academic Year 2014-2015 and 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 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. Furthermore, I understand that all information I provide in this form as well as during the UPCAT may be used by the University for research and I consent to such with the assurance that my personal details will be kept secure.

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 General Information Bulletin on Freshman Admission Academic Year 2014-2015 and agree to abide by the University rules and policies on student fees including tuition, scholarships, and financial assistance programs. I recognize that in signing this application form, I share with my son/daughter/dependent the responsibility for the veracity and completeness of the information supplied herein.

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. Specifically, check that: (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) a Certified True Copy of the certificate of Government Recognition or Government 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.