PAMANTASAN NG LUNGSOD NG VALENZUELA

APPLICATION FORM FOR COLLEGE ADMISSION TEST

APPLICATION NO. ROOM ASSIGNMENT TIME

INSTRUCTIONS: READ APPLICATION REQUIREMENTS BELOW. DO NOT APPLY IF NOT QUALIFIED. Fill in all the required information. DO NOT leave an item blank. If item is
not applicable, indicate “N/A”. Only fully accomplished form will be accepted. Credentials filed in support of this application will become the property of
this institution and will not be returned to the applicant.

A. NAME OF APPLICANT as it appears on the Birth Certificate

Last Name Paste a recent photograph

First Name
Requirements

Name Extension • Colored, Blue Background

• With handwritten name tag with
signature
(First Name/Middle Initial/Last Name/Name Ext.)
Middle Name

Passport Size ID Picture

B. FACTS OF BIRTH (3.5 x 4.5 cm)
Date of Birth (MM / DD / YYYY) Sex Citizenship Place of Birth (City, Municipality / Province)

/ /
Father’s Name (Last Name, First Name, Name Extension, Middle Name) Mother’s Maiden Name (Last Name, First Name, Name Extension, Middle Name)

C. CURRENT DEMOGRAPHIC DATA

Address House / Room / Floor / Block / Lot / Phase No. Street Name Subdivision Barangay City/Municipality District Zip Code

Civil Status Religion E-mail Address Mobile Number Telephone Number

D. EDUCATIONAL BACKGROUND
Track/Strand/Course Last Taken (Do Not Abbreviate) Expected Year of Graduation Section

Name of School Last Attended (Do Not Abbreviate) School Address

E. ORGANIZATIONAL AFFILIATION I. REQUIREMENTS EVALUATION

(To be accomplished by the PLV Personnel)
1. Name of Organization & Membership Classification Organization Classification

/ EXAMINEE TYPE:
2. Name of Organization & Membership Classification Organization Classification

/ EXAMINATION TYPE:
F. OTHER INFORMATION
1. Are you a person with disability? If yes, please specify
2. Are you a member of any indigenous group? If yes, please specify
3. Is your family a household-beneficiary of 4Ps?
APPLICATION REQUIREMENTS:
1. Fully accomplished downloaded application form and printed in a long
Bond paper (hand written forms will not be accepted)
2. Certified True Copy of Grade 11 (1st and 2nd Semester SY 2018-2019) report
card with GWA of 83% and above (two-sided copy)
3. Certified True Copy of Grade 12 (1st Semester SY 2019-2020) report card
with GWA of 83% and above (two-sided copy)

G. INTENDED COURSE (UNDERGRADUATE PROGRAM)
FIRST CHOICE (Course/Major):
SECOND CHOICE (Course/Major):
H. DECLARATION
I declare under oath that I personally accomplished this application form,
and I hereby certify that the information given are true, correct, and complete
statements. Further, I understand that the acceptance and approval of my application
for the examination is based on the aforestated information.
I therefore agree that, in case of post-verification yields information
contrary to what is declared, my application shall be disapproved, and my payment will
be forfeited. I further agree that any misinformation made in this document may cause
the invalidation of the result of this examination.
Further, I hereby give my consent to the Pamantasan ng Lungsod ng
Valenzuela that the abovementioned data may form part of its database that can be
used for relevant purposes but may not be limited to profiling and research, and
especially as basis of data-driven decisions of the University.
4. Certified True Copy of School ID (front and back)
5. Photocopy of NSO/PSA Birth Certificate (must be a Filipino citizen).
Bring the original copy for verification.
6. Photocopy of 2019 Voter’s Certification issued by COMELEC stating that
parent or the applicant is a Registered Voter of Valenzuela City.
Bring the original for verification.
7. Residence Vicinity Map with Valenzuela City Hall as starting point
(use the prescribed template)
8. Two (2) recent COLORED Passport Size ID Pictures in blue background with
handwritten name tag and signature
(First Name / Middle Initial / Last Name / Name Extension)
9. Non-Refundable amount of Php 250.00 application and examination fee
10. ALS/PEPT Certificate (For ALS/PEPT Qualifiers Only)
11. Transcript of Records with GWA of 83% and above
(For Transferring Students Only)

SIGNATURE OVER PRINTED NAME OF APPLICANT Evaluator Interviewer

THIS FORM IS NOT FOR SALE

(Print Only in 8.5 x 13 Bond Paper)
 PAMANTASAN NG LUNGSOD NG VALENZUELA
COLLEGE ADMISSION TEST
Name of Applicant:
Address:

RESIDENCE VICINITY MAP (Valenzuela City Hall as starting point)