VALID ONLY FOR UPCAT 2015

UPCAT Form 1 (Rev. 3-2014)

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 2015-2016
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

Staple a recent 2" X 2" photograph

(taken within the last six months) in this
box.

MIDDLE
2. SEX 1

Male 2

Female

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?

6. CITIZENSHIP 1
2

No 1

Staple here

Yes (Specify CMG and attach certification from NCIP)

Filipino (If born abroad please submit a photocopy of a valid Philippine passport or a BOI Identification Certificate)
Foreign (Specify)

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

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 5 UP Visayas, Iloilo City

4 UP Diliman, Quezon City
6 UP Los Baos, Laguna

7 UP Manila, Manila
9 UP Mindanao, Davao City
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)

1st choice

2nd choice

COURSE CODE

1st choice
2nd choice
1st choice
2nd choice

9. Are you also interested in entering an accelerated program leading to Medicine? 2

No

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
Dagupan City
0122
0126
San Fernando City, La Union
0125
Urdaneta City
Vigan City
0129
REGION 2 (CAGAYAN VALLEY)
0202
Aparri,Cagayan
Basco, Batanes
0201
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
Bacoor, Cavite
0499
0421
Batangas City
0403
Imus, Cavite
Lucena City
0424
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

0626
Roxas City
0602
San Jose, Antique
UP Visayas, Iloilo City
0624
REGION 7 (CENTRAL VISAYAS)
0725
Dumaguete City
Larena, Siquijor
0704
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

THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED.

1024
Oroquieta City
REGION 11 (DAVAO)
1121
UP Mindanao, Davao City
1124
Digos City
Tagum City
1123
REGION 12 (SOCCSKSARGEN)
1228
Cotabato City
Gen. Santos City
1225
1204
Kabacan, North Cotabato
1226
Koronadal City
Tacurong City
1227
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

11.

ARE YOU A CHILD OF A UP FACULTY OR EMPLOYEE?

No

Yes (If Yes, please attach UP HRDO certification)

Name of parent employed by UP

A. Category

12.

Official Designation

B. Tenure

College/Unit where employed

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

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

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

Province . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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.
Household
Members
(1)

Name

Citizenship

(2)

(3)

Civil
Status
(4)

Highest
Educational
Attainment
(5)

Present
Occupation
(6)

Employer

Income
(Annual Gross)

(7)

(8)

Other Sources
of Income?
(Yes or No)
(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)
(1)
(2)
(5)
(8)
(9)

For each of the Other Household Members, indicate the member's relationship to the student (e.g. grandmother, aunt, uncle, etc.)
Write DECEASED after name of deceased parent. Write down mother's maiden name.
Indicate the highest educational level which each household member actually completed (e.g. Elementary, High School, College Undergraduate, BA, BS, MBA or PhD).
INCOME includes wages and salaries, income from business/farm/profession, allowances, and investment income/earnings.
Other Sources of Financial Assistance in the Year 2013 outside of the Incomes of all household members.
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.

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.

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.

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

SIGNATURE OF PARENT/GUARDIAN

DATE

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.