INTERCONTINENTAL

COLLEGE
“Transnational Education Provider”

Lot 20 Block 30, Silver Corner, Marble Road, Pilar Village

Las Piñas City Philippines 1750.
Email: pic1@pic.edu.ph Contact Number: (632)872-0773; 478.7710
Website: www.pic.edu.ph

Fill up the Application Form below with the correct details.

Applicant’s
Information
Full Name: Lucila P. Molbog

Primary Email: lucila.molbog001@deped.gov.ph Status: Married

Facebook Account Name: Lucila Molbog Gender: Female

Contact Number:09565781983 Citizenship: Filipino

Place of Birth: Maranlig, Torrijos ,Marinduque Birthday May 30,1966

Address: Balanacan,Mogpog ,Marinduque

School Division Office: Division of Marinduque Principal: Garry R. Monteagudo

School: Balanacan ELem. School Position: T 1

PROGRAM YOU WANTED TO

ENROLL
Degree Program: BACHELOR / MASTER PHD

Preferred Major Study: Master of Arts in Education Major in Sped Education

Previous School Graduated:

Self Introduction:

Name of Recommender: Dr. Cherie B. Apolinario CP Nos. 09562814641/ 09951756047

E-mail: rochdelerie902@gmail.com Messenger: Cherie Apolinario
By filling this form you certify that the foregoing information are true and correct to the best of your knowledge and you fully
realize the omission or falsification of any information will be considered sufficient reason for the rejection or dismissal of this
application.
NOTE: Students who withdraw their application must request a written withdrawal statement from the Registrar’s Office
by Registered Mail. Postmark on the envelope determines the date of cancellation. The refund percentage is based on the total
tuition fee for the degree program and not from the amount paid.
NON-DICRIMINATORY DECLARATION
Pacific InterContinental College admits students and faculty of any race, creed, color, national and ethnic origin to all of the
rights, privileges, programs, and activities generally accorded or made available to students at the Institute. It does not
discriminate on the basis of race, color, creed, national and ethnic origin in the administration of its educational policies,
admissions policies, scholarships and other school - administered programs.

LUCILA P.MOLBOG
Applicant’s Signature: