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VALID ONLY FOR UPCAT 2013

UPCAT Form 1 (Rev. 3-2012)

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 2013-2014
TO THE STUDENT AND PARENTS/GUARDIAN:
Carefully read the GENERAL INFORMATION BULLETIN ON FRESHMAN ADMISSION before filling out this application form.

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:

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.

1.

Received by

Exemption Evaluator

TP Checker

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

S taple a recent 2" X 2" photograph
(taken within the last six months) in this box.

MIDDLE
2.

SEX 1

Male 2

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

7.

Female
-

Be sure to print your name at the back of the photo.

-

No 1

Staple here

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)

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

No 1

Year

Yes (Where)

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
2 UP Cebu, Cebu City

3 UP Extension Program Pampanga, Clarkfield, Pampanga
4 UP Diliman, Quezon City

5 UP Visayas, Iloilo City
6 UP Los Baños, Laguna

7 UP Manila, Manila
8 UP Tacloban College, Tacloban City

9 UP Mindanao, Davao 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

2nd choice

9.

INTENDED COURSE (See list of Undergraduate Degree Programs)

COURSE CODE

1st choice

1st choice

2nd choice

2nd choice

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)
0103
Batac, Ilocos Norte
0122
Dagupan City
0126
San Fernando City, La Union
0125
Urdaneta City
0129
Vigan City
REGION 2 (CAGAYAN VALLEY)
Aparri,Cagayan
0202
0201
Basco, Batanes
0206
Bayombong, Nueva Vizcaya
0207
Diffun, Quirino
0208
Ilagan, Isabela
0223
Tuguegarao City
REGION 3 (CENTRAL LUZON)
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
0403
Bacoor, Cavite

0421
Batangas City
0403
Imus, Cavite
0424
Lucena City
0428
Trece Martires City
0404
UP Los Baños, Laguna
REGION 4-B (MIMAROPA)
1701
Boac, Marinduque
Calapan City
1721
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)
Dumaguete City
0725
0704
Larena, Siquijor
0728
Tagbilaran City
0723
UP Cebu, Cebu City
REGION 8 (EASTERN VISAYAS)
0804
Borongan, Eastern Samar
Catarman, Northern Samar
0805
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

THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED.

1124
Digos City
1123
Tagum City
REGION 12 (SOCCSKSARGEN)
1228
Cotabato City
Gen. Santos City
1225
1204
Kabacan, North Cotabato
Koronadal City
1226
1227
Tacurong City
REGION 13 (CARAGA)
1321
Butuan City
Prosperidad, Agusan del Sur
1302
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

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

In active service

Part-time (e.g., lecturer, etc.)

Permanent

On leave with pay

With compensation

Contractual

On leave without pay

Without compensation

12.

Temporary

Casual

On secondment

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)

Postal/Zip Code . . . . . . . . . . . . . . . . . . . . . . .

Telephone No (2)
E-mail Address

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 2011 income tax returns or BIR certification/s.

MARITAL
CITIZENSHIP
STATUS

NAME

HIGHEST
EDUCATIONAL
ATTAINMENT

PRESENT
OCCUPATION

EMPLOYER

(Do not leave blank)
ANNUAL
GROSS INCOME
(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

16.

Have you ever attended any UPCAT review classes? 2

Yes

No 1

Yes

What are these schools?

Where/With what center?

I affirm that:
(1) I have read all the information contained in the General Information Bulletin on Freshman
Admission for Academic Year 2013-2014 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.

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 2013-2014 and agree to abide by the University rules and policies on student fees including tuition, scholarships, and financial assistance programs.

SIGNATURE OF STUDENT

SIGNATURE OF PARENT/GUARDIAN

DATE

DATE

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.

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 G overnment Recognition or Government Permit o f 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.

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