UPCAT Application Form
- 1. UPCAT Form 1 (Rev. 2-2011) TO BE FILLED OUT ONLY BY PERSONNEL AUTHORIZED TO RECEIVE AND/OR PROCESS APPLICATIONS. Document Inventory Number Testing Fee: P450 US$50 US$100 UNIVERSITY OF THE PHILIPPINES Exempted: UPCAT APPLICATION FOR FRESHMAN ADMISSION TOP 10 INCOME FIRST SEMESTER AY 2012-2013 Deficiency/cies: List of Top 10 across all curricular programs/annexes BIR Certificate / ITR / Cert of Compensation 2316 TO THE STUDENT AND PARENTS/GUARDIAN: Testing Fee F2 OTR GP/GR Affidavit Carefully read the GENERAL INFORMATION BULLETIN ON FRESHMAN PEPT GCSE/GCE Passport NBCR/ICR ADMISSION Remarks: 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 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. Staple here 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 Have you attended secondary level education anywhere else? 2 No 1 Yes (Where) High School Name & Address Year 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, Cebu City 5 UP Visayas, Iloilo City 8 UP Tacloban College, Tacloban 3 UP Extension Program Pampanga, Clarkfield, Pampanga 6 UP Los Baños, Laguna City Mindanao, Davao City 9 UP 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, 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 0207 Diffun, Quirino 1722 Puerto Princesa City 0806 Catbalogan, Western Samar REGION 13 (CARAGA) 0208 Ilagan, Isabela 1702 San Jose, Occidental Mindoro 0824 Maasin City 1321 Butuan City 0223 Tuguegarao City REGION 5 (BICOL) 0823 UP Tacloban College, Tacloban 1302 Prosperidad, Agusan del Sur REGION 3 (CENTRAL LUZON) 0502 Daet, Camarines Norte City 1322 Surigao City 0327 Balanga City 0522 Legazpi City REGION 9 (ZAMBOANGA PENINSULA) 1304 Tandag, Surigao del Sur 0307 Baler, Aurora 0525 Masbate City 0922 Dipolog City REGION 14 (CAR) 0322 Cabanatuan City 0523 Naga City 0923 Pagadian City 1403 Banaue, Ifugao 0332 Malolos City 0526 Sorsogon City 0924 Zamboanga City 1401 Bangued, Abra 0302 Meycauayan, Bulacan 0504 Virac, Catanduanes REGION 10 (NORTHERN MINDANAO) 1405 Bontoc, Mt. Province 0323 Olongapo City REGION 6 (WESTERN VISAYAS) 1022 Cagayan de Oro City 1407 Tabuk, Kalinga 0621 Bacolod City 1030 Iligan City 1421 UP Baguio, Baguio City 0326 Tarlac City 0601 Kalibo, Aklan 1028 Malaybalay City NATIONAL CAPITAL REGION 0321 UPEPP, Clarkfield, Pampanga 0626 Roxas City 1004 Mambajao, Camiguin 1624 UP Diliman, Quezon City 1024 Oroquieta City LAST FIRST THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED. MIDDLE
- 2. 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 Director.) 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) E-mail Address Postal/Zip Code . . . . . . . . . . . . . . . . . . . . . .. 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 2010 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 (1) the information which my son/daughter/dependent has provided Freshman Admission for Academic Year 2012-2013 and understood all the instructions in in this application form is true, complete, and accurate. connection with my application for the UPCAT; (2) I have read all information contained in the General (2) All the information supplied in this application form are true, complete, and accurate; Information Bulletin on Freshman Admission Academic Year (3) I have not taken the UPCAT previously and that I am not taking nor have I taken any 2012-2013 and agree to abide by the University rules and college subject in any school, college or university; and policies on student fees including tuition, scholarships, and (4) I will abide by the University rules and policies on test administration and on student fees financial assistance programs. including tuition, scholarships, and financial assistance programs. I recognize that in signing this application form, I share with my son/ I am aware that any or all the information furnished in this application may be checked against the daughter/dependent the responsibility for the veracity and original documents and that withholding information or giving false information will disqualify me completeness of the information supplied herein. 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 DAT DATE E 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 eac h 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.