Reference No.

: QF-ARC-034 Revision No: 01 Effectivity Date: December 1, 2021

LETTER OF DECLARATION AND WAIVER

First Year Degree or Non-Degree Program

I, Abuena, Pauline Grace S. , Filipino , of legal age and residing at

Family Name, First Name, M.I. Nationality
Mangandingay, Cabarroguis, Quirino hereby state that:
Address
1. I wish to apply for admission to the Bachelor of Science in Psychology program
(ex: Bachelor of Science in Civil Engineering)
Unaivtersity of Baguio, Baguio City ;

2. Prior to my application, I graduated from High School with the following details;

NAME OF SCHOOL ADDRESS OF SCHOOL ACADEMIC YEAR/TERM

Quirino General High School Zamora, Cabarroguis, Quirino S.Y 2021-2022

3. As of date of this Undertaking, I have not submitted the following admission document(s)/ record(s)

Please put a check mark whichever is applicable:

Original Copy of Grade 12 Report Card (SF 9)/SF10 Marriage Contract (Photocopy) - for married
female applicant & affidavit to use married
SA BPirth Certificate name in all her school records

thersO(please specify)

4. I am aware that the aforementioned document(s)/ record(s) is/are requirements for my acceptance at
University of Baguio. I am also aware that I have been provisionally accepted subject to the condition that the
original copies will be submitted to the Admissions and Records Center within thirty (30) working days from
the start of classes during the First Semester AY 2022-2023 or as may be further prescribed by the office.
5. I understand that if I FAIL to submit the aforementioned credentials, I shall give University of Baguio the right
to cancel my provisional enrollment, withhold the release of all my credentials/ Transcript of Records/
Diploma, and not demand any credit (unit) of work done nor will I claim a refund of the amount previously
paid for tuition fees and other school fees.
6. I have not registered, enrolled or been admitted at the tertiary level in any school in the Philippines or abroad;
7. I have not used or surrendered my High School Report Card, whether original or duplicate, to another school
for purposes of seeking admission at the tertiary level;
8. I have submitted an authentic and latest available copy of my school records from my last school attended;
9. Furthermore, I hereby waive any right of action against University of Baguio, its affiliates, representatives,
agents and/ or any of its duly constituted officers / employees that any misrepresentation or inaccuracy
contained in this Form and/or in the event that I will not be allowed to graduate because of my failure to
submit the original copy of the aforementioned document(s)/record(s) within the given period and/ or meet the
above conditions.

By affixing my signature over my name, I hereby expressly agree that I have read the entire content of this
undertaking and I fully understand its nature and purpose, and I agree to be legally bound by it.

Done this 23rd day of June , year 20 22 in the City of Baguio, Philippines.

PAULINE GRACE S. ABUENA NELSON V. ABUENA

Student Signature over Printed Name Parent/Guardian Signature over Printed Name
09552778504 09171450864
Contact No. (Mobile) Contact No. (Mobile)
abuenpaulinegrace@gmail.com nelson.abuena@gmail.com
Email Email

Note: Please attached identification card of Parent/Guardian with signatures.

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Reference No.: QF-ARC-034 Revision No: 01 Effectivity Date: December 1, 2020

LETTER OF DECLARATION AND WAIVER

PARENT/GUARDIAN IDENTIFICATION CARD

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