U.P. VANGUARD, INC.

Unit 209 Vanguard Bldg., U.P. Campus, Diliman, Quezon City PHOTO
Tels. 920-68-81 * Telefax (632) 920-68-89

RCN:___________________
(Pls. Leave this Blank)

APPLICATION FOR MEMBERSHIP

1. NAME: _________________________________________________________________________
(Last) (First) (Middle) (Nickname)

2. BIRTH: ____________ RELIGION: _____________ EMAIL ADD: _________________________

3. SEX: _____ HEIGHT: ________ WEIGHT: __________ BLOOD TYPE: __________

4. NATIONALITY: ______________________________ CIVIL STATUS: ________________

If married, name of spouse and address to include telephone no, if any:
_____________________________________________________________________________________

5. ADDRESS:
a.) Residential: ___________________________________________________________________

______________________________ ____ Telephone: _________________________

b.) Occupation: _______________________________ _______________________________

(Company/Firm/Establishment) (Position/Title/Designation)

____________________________________________________________ ___________
(Location) (Telephone)

6. TYPE OF MEMBERSHIP APPLIED FOR: / / Regular / / Honorary / /Associate

7. EDUCATION School Course Yr. Graduated

a.) Elementary ___________________ _______________ ______ __________

b.) Secondary ___________________ _______________ ______ __________

c.) College ___________________ _______________ ______ __________

d.) Additional ___________________ _______________ ______ __________

e.) Schooling ___________________ _______________ ______ __________

8. MILITARY

a.) Commissionship ________________________________________ ___________

(Present Rank/Grade) (Regular/Reserve) (Unit Assignment)

b.) Reservist Status _____________________________________________________________

(Rank/Grade) (Serial Number) (Unit Assignment)
 c.) ROTC
(1) Basic ________________________ __________________ ________
(School ROTC Unit) (Period Covered)

______________________ ___________ ____________________

(Highest Position/Designation Held) (Rank) (Year Graduated)

(2) Advance ______________________________ ________________________________

(School ROTC Unit) (Period Covered)

_________________________________ ____________ ___________________

(Highest Position/Designation Held) (Rank) (Year Graduated)

d.) Special Schooling / Training

______________________________ ________________________________
(School) (Course)

_________________________________ __________________________
(Period Covered) (Year Graduated)

9. SPECIAL TALENT / SKILLS:

______________________________________________

______________________________________________

______________________________________________

by Formal Schooling by Experience

10. AWARDS/ CITATIONS, AND COMMENDATIONS:

TYPE FROM /WHEN Date Acquired

____________________________________________________________ ___________

____________________________________________________________ ___________

____________________________________________________________ ___________

____________________________________________________________ ___________

____________________________________________________________ ___________

____________________________________________________________ ___________
11. SCHOLARSHIPS:

From Whom and Type Period of Enjoyment Where Applied/Utilized

__________________________ ________________________ _____________________

__________________________ ________________________ _____________________

__________________________ ________________________ _____________________

12. I certify that the forgoing information are true and correct to the best of my knowledge.

_______________________ __________________________
Date Signature

13. SPONSORING CHAPTER (Only as required. Must be active members of good standing of UPVI.
The applicant is responsible in securing these signatures.)

Chapter: ______________________________

Printed Name of Chapter Member & Signature

a)

b)

c)

d)

e)

14. RECOGNITION: (Applies only to recent Advance Graduate Applicants)

a) Place ______________________________________ Date: ________________

b) Recommended: / / Acceptance / / Deferment / / Rejection

(Rejection and/ or deferment must be followed by a formal report by the Control Officer
immediately after the recognition date)

______________________________________________
(Printed Name and Signature of Control Officer)

CHOICE OF CHAPTER AFFILIATION

(Please Check)

CAPITOL / / LOS BAÑOS / / UNIV / / MANILA / / MMLB / /

PASIG / / MAKATI / / CEBU / / DAVAO / / BAGUIO / /

AMIANAN / / PANAY-NEGROS / /