Republic of the Philippines

PAMANTASAN NG LUNSOD NG SAN PABLO

Barangay San Jose, City of San Pablo 1x1 picture
GRADUATE SCHOOL with
REGISTRATION FORM
complete
name

Student No.: GS___________

PROGRAM APPLIED FOR: 1st Sem 2nd Sem Midyear Reference No./OR No.
A.Y. 2023-2024
Instructions: Read General and Documentary Requirements. Fill in all the required information. Do not leave an item blank. If the item is not applicable, indicate “N/A”.
PERSONAL INFORMATION

NAME (Last Name) (First Name) Middle Name Maiden Name (for married woman)

Date of Birth Permanent Mailing Address/

(MM/DD/YYYY) - - Zip Code

Age Mobile Number

Place of Birth E-mail Address
Sex Male Female Nationality
Name of Relationship Occupation
Parent/Guardian
Civil Status: Student Type
Single Married Widowed Separated Continuing/Old Student Regular Irregular
New Enrollee
Returning Student
SCHOOL RECORD
Intermediate Year Graduated
High School Year Graduated
College Year Graduated
Highest Year Completed
Last School Attended
Degree Earned
COURSES ENROLLED
No. Course Code Course Title Units Time Days Section Professor
1
2
3
4
5
Total Number of Units

I HEREBY CERTIFY that all information indicated in this form and on the
Amount
documents attached in this application for Graduate School program are true and
OLD MIDYEAR NEW
correct and that any concealment or misrepresentation of facts therein found will ENROLLEES ENROLLEES
adversely affect my application. Tuition Fee 4,500 5,850 5,850
Likewise, I am fully aware that PLSP may share such information to affiliated or (500/unit) (650/unit)
Admission Fee 500 500 500
partner organizations as part of its contractual obligations, or with government Miscellaneous Fee 1,450 1,450 1,800
agencies pursuant to law or legal processes. In this regard, I hereby allow PLSP to Registration Fee 150 150 150
Medical/Dental Fee 100 100 100
collect, process, use and share my personal data in the pursuit of its legitimate Sanitation Fee 150 150 150
Energy Fee 300 300 300
academic, research, and employment purposes and/or interests as an educational
Internet Fee 300 300 300
institution. Library Fee 150 150 150
Security Fee 200 200 200
Insurance 100 100 100
______________________________________ Library Card 100
(Signature over Printed Name of Applicant) Student Handbook 100
Student ID 150

_______________ Total Fees (OLD) 6,450 7,800

Total Fees (NEW) 8,150
Date Accomplished An additional tuition fee of
220/unit for the
pre-requisite subjects
Approved by:
TOTAL
Assessed by: Certified by:
MS. VRENALI R. TOLENTINO PRECIOSA VILLACRUEL, LPT, PhD
Registrar II Dean, Graduate School Benjamin F. Maghirang Elilbert O. Singson
Account Officer Cashier I
1

PLSP-GS 002-A Revision No.: 02 Effectivity Date: February 2023 Page 1 of 1