7.

HIGH SCHOOL (where you completed/are completing secondary level education):

Have you attended secondary level education anywhere else? 2 No 1 Yes (Where)

Year of Graduation from Elementary Level
High School Name (Do not abbreviate) Month/Year of Completion
Address (City/Town,Province) Region
High School Name & Address
Year
THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED.
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.
2. SEX 1 Male 2 Female
3. DATE OF BIRTH (Month, Day, Year) - -
4. PLACE OF BIRTH (City/Town, Province)
5. MEMBER OF CULTURAL MINORITY GROUP? 2 No 1 Yes (Specify CMG and attach certification from NCIP)
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)
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
LAST
FIRST
MIDDLE
UPCAT Form 1 (Rev. 3-2014)
UNIVERSITY OF THE PHILIPPINES
UPCAT APPLICATION FOR FRESHMAN ADMISSION
FIRST SEMESTER AY 2015-2016
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:
{
{
TO BE FILLED OUT ONLY BY PERSONNEL AUTHORIZED TO RECEIVE
AND/OR PROCESS APPLICATIONS.
Document Inventory Number

Received by Exemption Evaluator TP Checker
VALI D ONLY FOR UPCAT 2015
8. UP CAMPUS APPLIED FOR: Choose from among the following (up to two choices allowed)
1 UP Baguio, Baguio City 3 UP Extension Program Pampanga, Clarkfield, Pampanga 5 UP Visayas, Iloilo City 7 UP Manila, Manila 9 UP Mindanao, Davao City
2 UP Cebu, Cebu City 4 UP Diliman, Quezon City 6 UP Los Baos, Laguna 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 INTENDED COURSE (See list of Undergraduate Degree Programs) COURSE CODE
1st choice
1st choice
2nd choice
2nd choice
1st 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)
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
0330 San Jose Del Monte 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
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
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
11. ARE YOU A CHILD OF A UP FACULTY OR EMPLOYEE?
2 No 1 Yes (If Yes, please attach UP HRDO certification)
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. PERMANENT HOME ADDRESS
Number and Street . . . . . . . . . . . . . . . . . . . .
Subdivision / Village, Barangay, District . . .
Town / City . . . . . . . . . . . . . . . . . . . . . . . . . . .
Province . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Postal/Zip Code
14. CONTACT INFORMATION
Telephone Number . . . . . . . . . . . . . . . . . . . .

Cellphone 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, please leave the space blank.
(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) Other Sources of Financial Assistance in the Year 2013 outside of the Incomes of all household members.
Household Civil Highest Present Income Other Sources
Members Name Citizenship Status Educational Occupation Employer
(Annual Gross)
of Income?
Attainment (Yes or No)
(1) (2) (3) (4) (5) (6) (7) (8) (9)
Applicant
Father
Mother

Sub-Total (a)
Brothers and Sisters (living in the household)

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

Sub-Total (c)
Name of parent employed by UP Official Designation College/Unit where employed
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 2015-2016 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 PARENT/GUARDIAN
DATE
I affirm that:
(1) I have read all the information contained in the General Information Bulletin on Freshman Admission for
Academic Year 2015-2016 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.
SIGNATURE OF STUDENT
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.
NOTE: If your annual family gross income is equal to or less than P 100,000, please attach a photocopy of your FAMILY'S 2013 income tax returns or BIR certification/s.