PAMANTASAN NG LUNGSOD NG VALENZUELA

SENIOR HIGH SCHOOL ADMISSION TEST (SHS-AT)

APPLICATION FORM PLVSHSAT2020

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 led 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 Certicate

Last Name ARGALLON

Paste a recent photograph

First Name MARK JOSEPH

Requirements

Name Extension N/A • Colored, Blue Background

• With hand held name tag
with signature
(First Name/Middle Initial/Last Name/Name Ext.)
Middle Name ARGALLON
DELOS SANTOS

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)

0 9 1 8 2 0 0 3 MALE FILIPINO VALENZUELA CITY

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

ARGALLON , ARNEL FALLER DELOS SANTOS , REBECCA SALAS

C. CURRENT DEMOGRAPHIC DATA

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

#5081 C. INDEPENDENCE STREET,GEN.T.DE LEON,VALENZUELA CITY 2 1442

Civil Status Religion E-mail Address Mobile Number Telephone Number

SINGLE CATHOLIC mirajanestrauss983@gmail.com 09212020691 N/A

D. EDUCATIONAL BACKGROUND
Name of Junior High School (Do Not Abbreviate) Expected Year of Completion Section

GENERAL TIBURCIO DE LEON NATIONAL HIGH SCHOOL 2020 10-FLAVIANO

School Address Learner Reference Number School Classication (e.g. Public, Private, Others)
CORNER MERCADO ST.,GEN.T. DE LEON,VALENZUELA CITY 1368140900582 PUBLIC SCHOOL

E. ORGANIZATIONAL AFFILATION
1. Name of Organization & Membership Classication Organization Classication 3. Name of Organization & Membership Classication Organization Classication
GR.10 SCHOOL
MATHEMATICS CLUB /REPRESENTATIVE N/A / N/A
ORGANIZATION
2. Name of Organization & Membership Classication Organization Classication 4. Name of Organization & Membership Classication Organization Classication
N/A / N/A N/A / N/A

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-beneciary of 4Ps?
NO NO NO
G. INTENDED TRACK & STRAND I. REQUIREMENTS EVALUATION
(To be accomplished by the PLV Personnel)
FIRST CHOICE (Track/Strand):

ACADEMIC TRACK/ GENERAL ACADEMIC STRAND

APPLICATION REQUIREMENTS
SECOND CHOICE (Track/Stand): 1. Certied True Copy of Grade 9 Report Card (School Year 2018-2019) with
SCIENCE,TECHNOLOGY,ENGINEERING GWA of 83% and above (Front and Back).
ACADEMIC TRACK/ AND MATHEMATICS STRAND
ACADEMIC TRACK 2. Certied True Copy of Grade 10 Report Card for the recent Grading Period
(School Year 2019-2020) with no grade lower than 80% per subject during
• ACCOUNTANCY, BUSINESS AND MANAGEMENT (ABM) STRAND
the time of application (Front and Back).
• GENERAL ACADEMIC (GA) STRAND
• HUMANITIES AND SOCIAL SCIENCES (HUMSS) STRAND
3. Certied True Copy of School ID (Front and Back).
• SCIENCE, TECHNOLOGY, ENGINEERING AND MATHEMATICS (STEM) STRAND

ARTS AND DESIGN TRACK 4. Photocopy of PSA/NSO Birth Certicate.

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-verication 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.
(Must be a Filipino Citizen)
5. Proof of Residency (2019 Voter’s Registration Certicate from the
COMELEC that parent or the applicant is a Registered Voter of Valenzuela).
6. Residence Vicinity Map (Valenzuela City Hall as starting point).
(Use the prescribed template)
7. Two (2) recent Passport Size ID Pictures with the following specications:
• Colored with blue background with hand held name tag with signature
(First Name / Middle Initial / Last Name / Name Extension)
8. Non-Refundable amount of Php 250.00 application and examination fee.

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 proling and research, and
especially as basis of data-driven decisions of the University.

MARK JOSEPH D. ARGALLON

Signature over Printed Name of Evaluator
SIGNATURE OVER PRINTED NAME OF APPLICANT

THIS FORM IS NOT FOR SALE

(Print Only in 8.5 x 13 Bond Paper)
 PAMANTASAN NG LUNGSOD NG VALENZUELA
SENIOR HIGH SCHOOL ADMISSION TEST (SHS-AT)

RESIDENCE VICINITY MAP (Valenzuela City Hall as starting point)