PACIFIC

INTERCONTINENTAL COLLEGE
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“Transnational Education Provider” Colored Picture

Lot 20 Block 30, Silver Corner, Marble Road, Pilar Village Las Piñas City Philippines 1750.
Email: pic1@pic.edu.ph Contact Number: (632)872-0773; 478.7710
Website: www.pic.edu.ph

Fill up the form below with correct details.

Applicant’s Information

Surname Name Middle Initial

Primary Email: Status:

Secondary Email: Gender:

Contact Number: Citizenship:

Place of Birth: Birthday:

Address:

City: Province:

Country: Zip Code:

PRC Number: PRC Registration Date:

PROGRAM YOU WANTED TO ENROLL

Degree Program: BACHELOR MASTER PHD
Preferred Major Study/Specialization:
Previous School Graduated:
Self-Introduction:
Name of Recommender:

By filling this form you certify that the foregoing information are true and correct to the best of your knowledge and you fully
realize the omission or falsification of any information will be considered sufficient reason for the rejection or dismissal of this
application.

NON-DICRIMINATORY DECLARATION
Pacific InterContinental College admits students and faculty of any race, creed, color, national and ethnic origin to all of the
rights, privileges, programs, and activities generally accorded or made available to students at the Institute. It does not
discriminate on the basis of race, color, creed, national and ethnic origin in the administration of its educational policies,
admissions policies, scholarships and other school - administered programs.

_____________________________________ _______________________
Applicant’s Signature: Date: