UPCAT Form No. 1 (Rev.

3-2006) TO BE FILLED OUT ONLY BY PERSONNEL AUTHORIZED TO RECEIVE AND/

OR PROCESS APPLICATIONS.

UNIVERSITY OF THE PHILIPPINES

UPCAT APPLICATION FOR FRESHMAN ADMISSION
FIRST SEMESTER AY 2007-2008
Deficiency/cies:
F2 OTR GP/GR Affidavit
PEPT GCSE/GCE/____ Testing Fee Top 10
ITRs of earning family members BIR Cert. Passport
TO THE STUDENT AND PARENTS:
Identification Cert. (Bureau of Immigration) ICR/NBCR

Carefully read the GENERAL INFORMATION ON FRESHMAN ADMISSION before filling out this application form. P450 US$50 US$100 EXEMPTED

Print legibly all information required. Only accomplished application forms, UPCAT Form 1 and UPCAT Received by TP DC
Form 2 (Secondary 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
2. SEX 1 Male 2 Female six months) in 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 High School Name

No Yes (Where)
education anywhere else?

Address School Year

8. U.P. CAMPUS APPLIED FOR.

Do not indicate the same campus twice. 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.

U. P. CAMPUS INTENDED COURSE (See list of Undergraduate Degree Programs) COURSE CODE
1st choice
1st choice { 2nd choice

1st choice
2nd choice
{ 2nd choice
Choose from among the following (up to two choices allowed)
1 U.P. Baguio, Baguio City 4 U.P. Diliman, Quezon City 7 U.P. Manila, Manila
2 U.P. Cebu College, Cebu City 5 U.P. Visayas, Iloilo City 8 U.P. Tacloban College, Tacloban City
3 U.P. Extension Program Pampanga, Clarkfield, Pampanga 6 U.P. Los Baos, Laguna 9 U.P. Mindanao, Davao City

9. Are you also interested in entering an accelerated program leading to Medicine? 1 Yes 2 No (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.
0103 Batac, Ilocos Norte 0403 Imus, Cavite 0804 Borongan, Eastern Samar 1227 Tacurong City
0122 Dagupan City 0404 U.P. Los Baos, Laguna 0805 Catarman, Northern Samar 1228 Cotabato City
0125 Urdaneta City 0421 Batangas City 0806 Catbalogan, Western Samar 1302 Prosperidad, Agusan del Sur
0126 San Fernando City, La Union 0424 Lucena City 0823 U.P. Tacloban Coll, Tacloban City 1304 Tandag, Surigao del Sur
0129 Vigan City 0502 Daet, Camarines Norte 0824 Maasin City 1321 Butuan City
0201 Basco, Batanes 0504 Virac, Catanduanes 0922 Dipolog City 1322 Surigao City
0202 Aparri,Cagayan 0522 Legazpi City 0923 Pagadian City 1401 Bangued, Abra
0206 Bayombong,Nueva Vizcaya 0523 Naga City 0924 Zamboanga City 1403 Banaue, Ifugao
0207 Diffun, Quirino 0525 Masbate City 1004 Mambajao, Camiguin 1405 Bontoc, Mt. Province
0208 Ilagan, Isabela del Norte 0526 Sorsogon City 1022 Cagayan de Oro City 1407 Tabuk, Kalinga
0223 Tuguegarao City 0601 Kalibo, Aklan 1024 Oroquieta City 1421 U.P. Baguio, Baguio City
0302 Meycauayan, Bulacan 0602 San Jose, Antique 1028 Malaybalay City 1624 U.P. Diliman, Quezon City
0307 Baler, Aurora 0621 Bacolod City 1030 Iligan City 1701 Boac, Marinduque
0321 UPEPP, Clarkfield, Pampanga 0624 U.P. Visayas, Iloilo City 1121 Davao City 1702 San Jose, Occidental Mindoro
0322 Cabanatuan City 0626 Roxas City 1123 Tagum City 1704 Cuyo, Palawan
0323 Olongapo City 0704 Larena, Siquijor 1124 Digos City 1705 Odiongan, Romblon
0326 Tarlac City 0723 U.P. Cebu Coll, Cebu City 1204 Kabacan, North Cotabato 1721 Calapan City
0327 Balanga City 0725 Dumaguete City 1225 Gen. Santos City 1722 Puerto Princesa City
0332 Malolos City 0728 Tagbilaran City 1226 Koronadal City

THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED.

11. ARE YOU A CHILD OF A U.P. FACULTY OR EMPLOYEE? Place an X in the appropriate box.

2 No

1 Yes Name of parent employed by U.P. Official Designation

College/Unit where employed Telephone No.

A. Status B. Tenure C. Place an X in only one box:

Full-time Temporary In active service On leave without pay

Part-time (e.g., lecturer, etc.) Permanent On leave with pay On secondment

With compensation Contractual

Without compensation Casual

12. ADDRESS AND TELEPHONE NUMBER. Print permanent home address and telephone number.

PERMANENT HOME ADDRESS

Number and Street . . . . . . . . . . . . . . . . . . . .

Subdivision / Village, Barangay, District . . .

Town / City . . . . . . . . . . . . . . . . . . . . . . . . . . .

Province . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Postal/Zip Code . . . . . . . . . . . . . . . . . . . . . . . Telephone No (1) Telephone No (2)

Cellphone Number . . . . . . . . . . . . . . . . . . . . . E-mail Address

13. 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 2005 income tax returns or BIR certification/s.

HIGHEST (Do not leave blank)

MARITAL PRESENT ANNUAL
NAME CITIZENSHIP EDUCATIONAL EMPLOYER GROSS INCOME
STATUS OCCUPATION
ATTAINMENT (in Phil. peso)

Father
Mother
(Maiden Name)

Legal Guardian

Subtotal
Is your Father/Mother/Legal Guardian a GSIS member? 1 Yes 2 No

BROTHERS AND SISTERS (Only those who are single):

1.
2.
3.
4.

Subtotal

14. Have you applied/are you planning to apply to other schools? 2 No 1 Yes What are these schools?

15. 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 and understood all the instructions in connection with my application for the UPCAT.
(2) 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.
(3) all the information supplied in this application form are true, complete and accurate.
(4) I have read all information contained in the General Information Bulletin On Freshman
Admission Academic Year 2007-2008 and agree to abide by the University rules and policies
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 or giving false information will disqualify me from
admission/will be a basis for dismissal, if admitted.
(1) the information which my son/daughter/dependent has furnished
in this application form are true, complete, and accurate.
(2) I have read all information contained in the General Information
Bulletin On Freshman Admission Academic Year 2007-2008 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 No. 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 NO. 2 (SECONDARY SCHOOL RECORD). DO NOT PASTE THE
PHOTOGRAPHS. EACH PHOTOGRAPH SHOULD HAVE YOUR PRINTED NAME AT THE BACK.