GUIDELINES IN ACCOMPLISHING THE PLV CAT 2023 APPLICATION FORM

1. FILL OUT THE PLV CAT 2023 APPLICATION FORM USING MS EXCEL APPLICATION
(HANDWRITTEN APPLICATION FORM WILL NOT BE ACCEPTED)

2. PRINT THE PLV CAT 2023 APPLICATION FORM IN A 8.5 X 13" (LONG) BOND PAPER.
PRINT THE FORM IN A BACK TO BACK SET UP.
(FORMS PRINTED IN 8.5 X 11" (SHORT) BOND PAPER WILL NOT BE ACCEPTED)

3. ATTACH ONE (1) PASSPORT SIZE ID PICTURE ON THE DESIGNATED AREA

4. CHECK THE COMPLETENESS AND CORRECTNESS OF THE INFORMATION/DATA ON THE

PLV CAT 2023 APPLICATION FORM

5. TYPE YOUR NAME AND SIGN THE APPLICATION FORM AND INDICATED THE PREPARATION
DATE WHEN YOU HAVE ACCOMPLISHED THE FORM

6. ARRANGE THE APPLICATION FORM AND THE REQUIRED DOCUMENTARY REQUIREMENTS

IN ORDER BASED ON THE APPLICATION POSTING
 PAMANTASAN NG LUNGSOD NG VALENZUELA PLV CAT APPLICATION NO.
COLLEGE ADMISSION TEST
SCHOOL YEAR 2023-2024

INSTRUCTIONS: READ THE APPLICATION QUALIFICATIONS. DO NOT APPLY IF NOT QUALIFIED. Fill in all the required information. DO NOT leave an item blank. If an 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 ofthis institution and will not be
returned to the applicant.

A. NAME OF APPLICANT (AS IT APPEARS ON THE BIRTH CERTIFICATE)

1 LAST NAME HERMOSURA
FIRST NAME DANETTE NAME EXTENSION N/A
MIDDLE NAME MONTON
B. FACTS OF BIRTH
2 DATE OF BIRTH (MM/DD/YYY) 3 PLACE OF BIRTH (CITY/MUN./PROVINCE) 4 GENDER 5 CITIZENSHIP 6 AGE

3 24 2004 CABA LA UNION FEMALE FILIPINO 18

7 BLOOD TYPE 8 CIVIL STATUS 9 RELIGION 10 BIRTH ORDER 11 NO. OF SIBLINGS

UNKNOWN SINGLE CATHOLIC SECOND 1

C. ADDRESS & CONTACT DETAILS
12 CURRENT ADDRESS HOUSE/ROOM/FLOOR/BLOCK /LOT/PHASE/STREET/SUBD. BARANGAY CITY/MUNICIPALITY DISTRICT ZIP CODE

270 AREA 2 FAMILY COMPOUND PADRINAO ST. KARUHATAN VALENZUELA II 1441

13 PERMANENT ADDRES HOUSE/ROOM/FLOOR/BLOCK /LOT/PHASE/STREET/SUBD. BARANGAY CITY/MUNICIPALITY DISTRICT ZIP CODE

270 AREA 2 FAMILY COMPOUND PADRINAO ST. KARUHATAN VALENZUELA II 1441

14 ACTIVE EMAIL ADDRESS 15 SOCIAL MEDIA (FACEBOOK URL ADDRESS/ID) 16 ACTIVE MOBILE NUMBER 17 TELEPHONE NUMBER
https://www.facebook.com/danette.hermosura.9069566710319
danettehermosura18@@gmail.com N/A
D. FAMILY DATA
FIRST NAME MIDDLE NAME LAST NAME NAME EXTENSION PHYSICAL EXISTENCE
18 FATHER'S INFORMATION
DANNY BOY GABRILLO HERMOSURA N/A ALIVE
AGE HIGHEST EDUCATIONAL ATTAINMENT CURRENT OCCUPATION AVERAGE INCOME PER MONTH MOBILE NUMBER TELEPHONE NUMBER

46 UNDER GRADUATE COOK 4,725 N/A N/A

FIRST NAME MAIDEN MIDDLE NAME MAIDEN LAST NAME NAME EXTENSION PHYSICAL EXISTENCE
19 MOTHER'S INFORMATION
ANTONITH MONTON MUSTACHO N/A ALIVE
AGE HIGHEST EDUCATIONAL ATTAINMENT CURRENT OCCUPATION AVERAGE INCOME PER MONTH MOBILE NUMBER TELEPHONE NUMBER

44 HIGH SCHOOL GRADUATE OFW N/A N/A N/A

20 MARITAL STATUS OF PARENTS 21 APPLICANT'S LIVING STATUS 22 HOME OWNERSHIP STATUS 23 TOTAL NO. OF HOUSEHOLD MEMBER

SEPARATED LIVING WITH FATHER ONLY RENTING 2

24 TOTAL NO. OF HOUSEHOLD MEMBER WITH WORK 25 GROSS MONTHLY FAMILY INCOME 26 TOTAL MONTHLY EXPENSES

1 5001-10000 5001-10000
27 GUARDIAN'S DETAIL FIRST NAME MIDDLE NAME LAST NAME NAME EXT. RELATIONSHIP MOBILE NUMBER

DANNY BOY GABRILLO HERMOSURA N/A N/A N/A

E. EDUCATIONAL BACKGROUND
28 ARE YOU CURRENTLY ENROLLED? NO 29 IF "YES" WHAT PROGRAM IS IT? N/A
30 NAME OF SCHOOL LAST ATTENDED (DO NOT ABBREVIATE) MALINTA NATIONAL HIGH SCHOOL- SENIOR HIGH
31 SCHOOL'S MAILING ADDRESS (NOT THE EMAIL ADDRESS) ST.JUDE ST, ST. JUDE SUBDIVISION MALINTA, VALENZUELA CITY
32 Academic
TRACK/STRAND/PROGRAM/COURSE/MAJOR LAST TAKEN (OR YOU ARE CURRENTLY ENROLLED) Track - Humanities and Social Sciences Strand
33 LEARNER REFERENCE NO. 34 ESC NO. (IF APPLICABLE) 35 DATE OF GRADUATION 36 NO. OF SEMESTER COMPLETED (IF APPLICABLE)

136797090147 N/A JUNE 27, 2022 4

37 ENROLLMENT HISTORY NAME OF SCHOOL SCHOOL'S MAILING ADDRESS PERIOD OF ATTENDACE (FROM - TO)

COLLEGE/VOCATIONAL N/A N/A N/A

GRADE 12 ST. JUDE MALINTA NATIONAL HIGH SCHOOL - SENIOR HIGH ST. JUDE ST, ST.JUDE SUBDIVISION MALINTA, VALENZUELA CITY 2021 - 2022

GRADE 11 ST. JUDE MALINTA NATIONAL HIGH SCHOOL - SENIOR HIGH ST. JUDE ST, ST. JUDE SUBDIVISION MALINTA VALENZUELA CITY 2020 - 2021

GRADE 10 MALINTA NATIONAL HIGH SCHOOL A PABLO ST. MALINTA, VALENZUELA CITY 2019 - 2020

GRADE 9 MALINTA NATIONAL HIGH SCHOOL A PABLO ST. MALINTA, VALENZUELA CITY 2018 - 2019

GRADE 8 MALINTA NATIONAL HIGH SCHOOL A. PABLO ST. MALINTA, VALENZUELA CITY 2017 - 2018

GRADE 7 ST. JUDE SUBDIVISION MALINTA NATIONAL HIGH SCHOOL ST. JUDE ST, ST. JUDE SUBDIVISION MALINTA VALENZUELA CITY 2015 - 2016

F. INTENDED COURSE OF STUDY (UNDERGRADUATE PROGRAM)

38 FIRST CHOICE (COURSE/MAJOR) Bachelor of Science in Information Technology (BSIT)

39 SECOND CHOICE (COURSE/MAJOR) Bachelor of Arts in Communication Major in Theater Arts (BACTA)

WHY DO YOU CHOOSE THE FOLLOWING COURSE?

Through our upgraded technology I want to test my skills. I chose BSIT because I want to learn more, not just in editing video or present the ppt. Furthermore, I want to hone my skills

 and apply everything that I will learn in our everyday lives and share to others what I learned. I chose BACTA because I want to express myself through dancing, which I enjoyed,

and I want to perform again in stage or in theater.

DANETTE M. HERMOSURA FEBRUARY 26, 2023

Printed Name of Applicant Signature of the Applicant Date

 PAMANTASAN NG LUNGSOD NG VALENZUELA
COLLEGE ADMISSION TEST
SCHOOL YEAR 2023-2024

G. ORGANIZATIONAL AFFILIATION
40A NAME OF ORGANIZATION N/A 40B NAME OF ORGANIZATION N/A
TYPE OF ORGANIZATION N/A TYPE OF ORGANIZATION N/A
POSITION ON THE ORGANIZATION N/A POSITION ON THE ORGANIZATION N/A
40C NAME OF ORGANIZATION N/A 40D NAME OF ORGANIZATION N/A
TYPE OF ORGANIZATION N/A TYPE OF ORGANIZATION N/A
POSITION ON THE ORGANIZATION N/A POSITION ON THE ORGANIZATION N/A
H. OTHER INFORMATION
ARE YOU A PERSON WITH DISABILITY? NO
41 IF "YES", PLEASE SPECIFY THE TYPE OF DISABILITY N/A
PLEASE PROVIDE THE PWD ID NO. N/A
DO YOU HAVE ILLNESS / MEDICAL CONDITION? NO
42 IF "YES", PLEASE SPECIFY THE DETAILS OF ILLNESS
N/A
MEDICAL CONDITION

ARE A MEMBER OF ANY INDIGENOUS GROUP? NO

43
IF "YES", PLEASE SPECIFY THE DETAILS N/A

44 IS YOUR FAMILY A HOUSEHOLD BENEFICIARY OF 4PS? NO

45 ARE YOU RELATED BY CONSANGUINITY/AFFINITY TO ANY PLV EMPLOYEE? IF "YES", PLEASE SPECIFY THE DETAILS NO

45A NAME OF THE PLV EMPLOYEE N/A 45B NAME OF THE PLV EMPLOYEE N/A
DEPARTMENT OF THE EMPLOYEE N/A DEPARTMENT OF THE EMPLOYEE N/A
RELATIONSHIP TO THE EMPLOYEE N/A RELATIONSHIP TO THE EMPLOYEE N/A
45C NAME OF THE PLV EMPLOYEE N/A 45D NAME OF THE PLV EMPLOYEE N/A
DEPARTMENT OF THE EMPLOYEE N/A DEPARTMENT OF THE EMPLOYEE N/A
RELATIONSHIP TO THE EMPLOYEE N/A RELATIONSHIP TO THE EMPLOYEE N/A
46 ARE YOU RELATED BY CONSANGUINITY/AFFINITY TO ANY VALENZUELA CITY GOVERNMENT EMPLOYEE? IF "YES", PLEASE SPECIFY THE DETAILS NO

46A NAME OF THE VCG EMPLOYEE N/A 46B NAME OF THE VCG EMPLOYEE N/A
DEPARTMENT OF THE EMPLOYEE N/A DEPARTMENT OF THE EMPLOYEE N/A
RELATIONSHIP TO THE EMPLOYEE N/A RELATIONSHIP TO THE EMPLOYEE N/A
46C NAME OF THE VCG EMPLOYEE N/A 46D NAME OF THE VCG EMPLOYEE N/A
DEPARTMENT OF THE EMPLOYEE N/A DEPARTMENT OF THE EMPLOYEE N/A
RELATIONSHIP TO THE EMPLOYEE N/A RELATIONSHIP TO THE EMPLOYEE N/A
47 DO YOU HAVE ANY FAMILY MEMBER/S WITHIN THE 3RD DEGREE OF CONSANGUINITY WHO GRADUATED/STUDIED/OR CURRENTLY ENROLLED AT PLV?
NO
IF "YES, PLEASE SPECIFY THE DETAILS

47A NAME OF THE STUDENT N/A 47B NAME OF THE STUDENT N/A
COURSE & MAJOR N/A COURSE & MAJOR N/A
YEAR GRADUATED / ATTENDANCE N/A YEAR GRADUATED / ATTENDANCE N/A
RELATIONSHIP TO THE STUDENT N/A RELATIONSHIP TO THE STUDENT N/A
47C NAME OF THE STUDENT N/A 47D NAME OF THE STUDENT N/A
COURSE & MAJOR N/A COURSE & MAJOR N/A
YEAR GRADUATED / ATTENDANCE N/A YEAR GRADUATED / ATTENDANCE N/A
RELATIONSHIP TO THE STUDENT N/A RELATIONSHIP TO THE STUDENT N/A
I. DECLARATION
I declare under oath that I personally accomplished this application form, and I hereby certify that all the information
given are true, correct, and complete statements. Further, I understand that the acceptance and approval of my application for admission 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 I will be disqualified to apply.

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 a basis of
data-driven decisions of the University.

DANETTE M. HERMOSURA FEBRUARY 26, 2023

Printed Name of Applicant Signature of the Applicant Date