REPUBLIC OF THE PHILIPPINES Reference Number:

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES 2022-0031-8836

OFFICE OF THE UNIVERSITY REGISTRAR
ADMISSION AND REGISTRATION SERVICES
STA. MESA, MANILA Selected NSTP:
CWTS
SAR-FORM 1
WITH CONFIRMATION DOCUMENTS

Confirmation Slip (For a 4 or 5-year degree, or 3-year diploma program)

The University Admission Committee, Attach
MARIELLE ANGELA GENABE GONZALES recent 2x2" photo
I am ,
(Name) Here
graduated in 2022
from BULALACAO NATIONAL HIGH SCHOOL
would like to confirm my interest to be admitted and enrolled this First Semester, Academic Year 2022-2023 in a program where I am qualified based on
the Specific College Criteria.

BACHELOR OF SCIENCE IN APPLIED MATHEMATICS (BSAPMATH)

Respectfully yours,

MARIELLE ANGELA GENABE GONZALES

Signature over Printed Name of Applicant Note: Read carefully the freshman admission and enrollment procedure

This form contains personal-identifiable information that is subject to Data Privacy

Please keep this form protected and in a safe place

REPUBLIC OF THE PHILIPPINES Reference Number:
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES 2022-0031-8836
OFFICE OF THE UNIVERSITY REGISTRAR
ADMISSION AND REGISTRATION SERVICES
STA. MESA, MANILA Selected NSTP:
CWTS
SAR-FORM 1
WITH CONFIRMATION DOCUMENTS

Confirmation Slip (For a 4 or 5-year degree, or 3-year diploma program)

The University Admission Committee, Attach
recent 2x2" photo
I am MARIELLE ANGELA GENABE GONZALES ,
Here
(Name)
graduated in 2022
from BULALACAO NATIONAL HIGH SCHOOL
would like to confirm my interest to be admitted and enrolled this First Semester, Academic Year 2022-2023 in a program where I am qualified based on
the Specific College Criteria.

BACHELOR OF SCIENCE IN APPLIED MATHEMATICS (BSAPMATH)

Respectfully yours,

MARIELLE ANGELA GENABE GONZALES

Signature over Printed Name of Applicant Note: Read carefully the freshman admission and enrollment procedure

This form contains personal-identifiable information that is subject to Data Privacy

Please keep this form protected and in a safe place
 FRESHMAN ADMISSION AND ENROLLMENT PROCEDURE
ACADEMIC YEAR 2022-2023

Name of Applicant: MARIELLE ANGELA GENABE GONZALES

Reference Number: 2022-0031-8836 Date of Enrollment: Wednesday, June 15, 2022
SHS Track/Strand: STEM

Note: Read carefully the Freshman Admission and Enrollment Procedure

1. Online Confirmation
1.1. Download this Confirmation Slip. You are given five (5) days to confirm. Non-confirmation on the prescribed period would mean
forfeiture of your slot.
1.2. Submit the following documents upon enrollment:
1.2.1. Required Credentials:
Upon confirmation, enrollee must submit personally or through courier service the original and photocopies of the following
documents to the Admission and Registration Services Section on or before August 31, 2022:

PUP Admission and Registration Services For further inquiries, clarifications, or in case of
G/F Room 117 West Wing Main Building error, email admission.main@pup.edu.ph
Anonas St., Brgy 630, Sta. Mesa, Manila 1016 with Message Subject: Freshman Online
Enrollment – Sta. Mesa Manila

1.2.1.1 For Graduates of Senior High School AY 2021-2022

a) Original or certified true copy of grades 10 and 11 high school card.
b) Original Grade 12 Senior High School Card (F138) with school dry seal.
c) Original PSA Birth Certificate.
d) Certification of Good Moral issued by the SHS Principal/or Guidance Counselor with school dry seal.
e) Duly signed Waiver/Certification Under Oath. (Waiver is attached in this Confirmation Slip)
f) Two (2) pcs of 2x2 inches colored picture with white background and with the applicant's name on the photo.
g) Hard copy of completely filled-out PUP Health Information Form for Student. The blank sheet is downloadable from
PUP website. The filled-out form must have a 2x2 or passport size colored picture and signed by parent/guardian (if
student is below 18 years old)
h) One (1) pc. long brown envelope (this will be used for the Health Information Form)

1.2.1.2 For Previous Senior High School Graduates/High School Graduates of Past School Year/s
In addition to the above admission requirements:
i) Certification from the respective senior high school registrar with school dry seal and noted by the Principal that no copy
of F137A has been sent to other college or university.
j) Notarized Waiver that if there is concealment of previous enrollment, PUP enrollment becomes null and void.

1.2.1.3 For Graduates of Alternative Learning System

a) Certificate of Completion
b) Certificate of Rating
c) Verified/Certified True Copy of National List of Passers which shows the name of the applicant
d) Certificate of Good Moral Character issued by the school last attended
e) PSA Birth Certificate
f) Two (2) pcs of 2x2 inches colored picture with white background and with the applicant's name on the photo.
g) One (1) pc. long brown envelope

2. Downloading and Printing of Registration Card

Wait for further announcement via PUP social media accounts on how to download your Registration Certificate as proof of your
official enrollment in PUP.

These documents contain personal-identifiable information that is subject to Data Privacy.

Please keep these documents protected and in a safe place.
 PUP-HIFS-6-MEDS-020
Rev.2
March 22, 2022
Republic of the Philippines
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES
Office of the Vice President for Administration
MEDICAL SERVICES DEPARTMENT
2x2 or passport size
Current colored ID photo
HEALTH INFORMATION FORM FOR STUDENT
PART I. STUDENT INFORMATION
Due to Covid-19 pandemic, physical examination, and chest x-ray submission as requirement for enrollment is temporary deferred,
however, you will be asked to comply with this upon resumption of your face-to-face classes

Name: PUP Student No.:

Home Address: School Year:
Age: Sex: Civil Status: Course / College:
Blood Type: Email Address:
Parent's Name / Guardian / Spouse:
Landline: Cellphone:

PART II. MEDICAL HISTORY

1. Do you need medical attention or has known medical illness? ⬜ No ⬜ Yes
(Pleas e check the following that apply and give more information as needed)
⬜ Asthma ⬜ Loss of Consciousness ⬜ Eye Disease/Defect ⬜ Accident Injuries
⬜ Diabetes ⬜ Heart Disease ⬜ Kidney Disease ⬜ Tuberculosis / Primary Complex
⬜ Convulsion/Epilepsy⬜ Hyperventilation ⬜ Hemophilia
⬜ Migraine ⬜ High Blood Pressure
⬜ Others (Pls. Indicate):

3. Additional Information for Students with Medical Conditions:

As a Parent/Guardian, I would like to declare that my child had history of allergies to the following:
Food: No Known Allergies:
Medicines: ⬜ Aspirin ⬜ Ibuprofen ⬜ Amoxicillin
⬜ Mefenamic Acid ⬜ Penicillin ⬜ Others: _____________________

PART III. PERSONAL SOCIAL HISTORY

Cigarette Smoking: ⬜ Yes ⬜ No
Alcohol Drinking: ⬜ Yes ⬜ No

I hereby state to the best of my knowledge, my answers to the above questions are complete and correct.

By affixing my signature (Parent/Guardian and Student), I agree to the Data Privacy Act of 2012 and its implementing
rules and regulations and voluntarily giving my consent in the collection and processing of the student's name above its
Personal Information in accordance with such as health assessment, treatment and/or research following research ethics
guidelines for the improvements of healthcare services. This consent will remain in full force until I revoke it in writing. I
also understand the PUP MSD will not be liable to any untoward incident this may arise due to the temporary deferral of
the physical examination and chest x-ray.

Signature of Parent/Guardian Signature of Student Date

Note: Both Parent/Guardian and Student will sign if Student is below 18 years of age.
 ver. 2021 (Form 2)

CERTIFICATION/UNDERTAKING

I, , of legal age, Filipino, with residence and postal address at

, hereby certify THAT:

1. I am an enrollee of Polytechnic University of the Philippines (PUP),

(Please check one): ▢ Sta. Mesa, Manila
▢ Branch/Campus: ____________________________________________________________
(State the Branch/Campus)

2. In compliance with the documentary requirements of the aforementioned University, among others, I am
submitting/undertake to submit the following documents on or before August 31, 2022:
a. Original or certified true copy of grade 10 & 11 high school card.
b. Original Senior High School Card (F138) with school dry seal.
c. Notarized certification of non-enrollment for high school/senior high school graduates who have not enrolled
in any technical/diploma/degree program immediately after graduation.
d. Original PSA Birth Certificate.
e. Certificate of Good Moral issued by the SHS Principal/or Guidance Counselor with school dry seal.
f. Duly signed Certification Under Oath, Form 2
g. Two (2) pcs. 2 in. x 2 in. colored picture with white background with applicant's name on the photo.
h. One (1) pc. long brown envelope.
For Senior High School Graduates/High School Graduates of Past School Year/s
In addition to the above admission requirements:
i. Certification from senior high school registrar with school dry seal and noted by the Principal that no copy of
F137A has been sent to other college or university.
j. Notarized certification of non-enrollment for senior high school graduates who have not enrolled in any
technical/diploma/degree program immediately after graduation with "waiver" that if there is concealment of
previous enrollment, PUP enrollment becomes null and void.
For Graduates of Alternative Learning System
a. Certificate of Completion
b. Certificate of Rating
c. Verified/Certified True Copy of National List of Passers which shows the name of the applicant
d. Certificate of Good Moral Character issued by the school last attended
e. PSA Birth Certificate
f. Two (2) pcs of 2x2 inches colored picture with white background and with the applicant's name on the photo.
g. One (1) pc. long brown envelope
3. I vouch the authenticity and genuineness of the documents I submitted/will submit to PUP;
4. I undertake and assume full and complete responsibility for all the consequences which may arise in case any of the
documents I submitted is found to have been falsified or fabricated;
5. I VOUCH THAT I HAVE NOT ENROLLED IN ANY HIGHER EDUCATION INSTITUTION INCLUDING ANY
BRANCH OR CAMPUS OF PUP OTHERWISE MY ENROLLMENT WILL BE CANCELLED.
6. I understand that my admission is merely provisional and that the University reserves its right to deny my application
for enrollment or revoke my enrollment should the information I declared or documents submitted have been found to
be deceitful, fabricated and falsified without prejudice to filing a criminal case against me; and
7. I am executing this Undertaking in order for the University to proceed with my enrollment.

__________________________________________
Signature above Printed Name of Enrollee
Date: __________________
ATTESTED by:

____________________________________________
Signature above Printed Name of Parent/Guardian