UPCAT Form 1 (Rev.

3-2013) VALID ONLY FOR UPCAT 2014

TO BE FILLED OUT ONLY BY PERSONNEL AUTHORIZED TO RECEIVE

AND/OR PROCESS APPLICATIONS.
Document Inventory Number

Testing Fee:
P450 US$50 US$100
UNIVERSITY OF THE PHILIPPINES Exempted:
UPCAT APPLICATION FOR FRESHMAN ADMISSION TOP 10 INCOME
FIRST SEMESTER AY 2014-2015 Deficiency/cies:
List of Top 10 across all curricular programs/annexes
BIR Certificate / ITR / Cert of Compensation 2316
TO THE STUDENT AND PARENTS/GUARDIAN: Testing Fee
F2 OTR GP/GR Affidavit
Carefully read the GENERAL INFORMATION BULLETIN ON FRESHMAN PEPT GCSE/GCE Passport NBCR/ICR
ADMISSION before filling out this application form. Remarks:

Print legibly all information required. Place X marks in appropriate boxes. Only
accomplished application forms, UPCAT Form 1 and UPCAT Form 2 (Secondary
School Record) will be processed.
Received by Exemption Evaluator TP Checker

1. NAME OF STUDENT: Print or type your full name in the following sequence: LAST NAME, FIRST NAME, MIDDLE NAME. Place one letter in each box. Leave one box blank between names.

LAST

Staple here
FIRST

MIDDLE
Staple a recent 2" X 2" photograph
(taken within the last six months) in this
2. SEX 1 Male 2 Female
box.

3. DATE OF BIRTH (Month, Day, Year) - - Be sure to print your name at the back
of the photo.
4. PLACE OF BIRTH (City/Town, Province)

5. MEMBER OF CULTURAL MINORITY GROUP? 2 No 1 Yes (Specify) Staple here

6. CITIZENSHIP 1 Filipino (If born abroad please submit a photocopy of a valid Philippine passport or a BOI Identification Certificate)

2 Foreign (Specify) 3 Dual (Specify)

7. HIGH SCHOOL (where you completed/are completing secondary level education):

High School Name (Do not abbreviate) Month/Year of Completion

Address (City/Town,Province) Region

High School Name & Address Year

Have you attended secondary level education anywhere else? 2 No 1 Yes (Where)

Year of Graduation from Elementary Level

8. UP CAMPUS APPLIED FOR: Choose from among the following (up to two choices allowed)
1 UP Baguio, Baguio City 3 UP Extension Program Pampanga, Clarkfield, Pampanga 5 UP Visayas, Iloilo City 7 UP Manila, Manila 9 UP Mindanao, Davao City
2 UP Cebu, Cebu City 4 UP Diliman, Quezon City 6 UP Los Baños, Laguna 8 UP Tacloban College, Tacloban City 10 UP Open University

Do not indicate the same campus twice. Make sure that course choices are offered in the campus indicated. Write NONE on the blank if you do not have other choices of campus/course.
Countersign all erasures and corrections made. Do not indicate INTARMED or Medicine in any of the blanks for Intended Course. Please refer to question No. 9 below.

UP CAMPUS INTENDED COURSE (See list of Undergraduate Degree Programs) COURSE CODE
1st choice
1st choice
{ 2nd choice

1st choice
2nd choice
{ 2nd choice

9. Are you also interested in entering an accelerated program leading to Medicine? 2 No 1 Yes (Only those indicating their interest will be considered for this program)

10. UPCAT TEST CENTERS (by Region). Mark the UPCAT Test Center nearest your school. (Mark only one.)

NOTE: Whenever possible, applicants will be issued Test Permits for a testing center in their respective provinces.

REGION 1 (ILOCOS) 0499 Bacoor, Cavite 0624 UP Visayas, Iloilo City REGION 11 (DAVAO)
REGION 7 (CENTRAL VISAYAS) 1121 UP Mindanao, Davao City
0103 Batac, Ilocos Norte 0421 Batangas City
0122 Dagupan City 0403 Imus, Cavite 0725 Dumaguete City 1124 Digos City
0126 San Fernando City, La Union 0424 Lucena City 0704 Larena, Siquijor 1123 Tagum City
0125 Urdaneta City 0428 Trece Martires City 0728 Tagbilaran City REGION 12 (SOCCSKSARGEN)
0129 Vigan City 0404 UP Los Baños, Laguna 0723 UP Cebu, Cebu City 1228 Cotabato City
REGION 2 (CAGAYAN VALLEY) REGION 4-B (MIMAROPA) REGION 8 (EASTERN VISAYAS) 1225 Gen. Santos City
0202 Aparri,Cagayan 1701 Boac, Marinduque 0804 Borongan, Eastern Samar 1204 Kabacan, North Cotabato
0201 Basco, Batanes 1721 Calapan City 0805 Catarman, Northern Samar 1226 Koronadal City
0206 Bayombong, Nueva Vizcaya 1704 Cuyo, Palawan 0806 Catbalogan, Western Samar 1227 Tacurong City
0207 Diffun, Quirino 1705 Odiongan, Romblon 0824 Maasin City REGION 13 (CARAGA)
0208 Ilagan, Isabela 1722 Puerto Princesa City 0801 Naval, Biliran 1321 Butuan City
0223 Tuguegarao City 1702 San Jose, Occidental Mindoro 0822 Ormoc City 1302 Prosperidad, Agusan del Sur
REGION 3 (CENTRAL LUZON) REGION 5 (BICOL)
0823 UP Tacloban College, Tacloban City 1322 Surigao City
0399 Angeles City 0502 Daet, Camarines Norte REGION 9 (ZAMBOANGA PENINSULA)
0327 Balanga City 0522 Legazpi City 1304 Tandag, Surigao del Sur
0922 Dipolog City REGION 14 (CAR)
0307 Baler, Aurora 0525 Masbate City
0322 Cabanatuan City 0523 Naga City 0923 Pagadian City 1403 Banaue, Ifugao
0332 Malolos City 0526 Sorsogon City 0924 Zamboanga City 1401 Bangued, Abra
0302 Meycauayan, Bulacan 0504 Virac, Catanduanes REGION 10 (NORTHERN MINDANAO) 1405 Bontoc, Mt. Province
0323 Olongapo City REGION 6 (WESTERN VISAYAS) 1022 Cagayan de Oro City 1407 Tabuk, Kalinga
0326 Tarlac City 0621 Bacolod City 1030 Iligan City 1421 UP Baguio, Baguio City
0321 UPEPP, Clarkfield, Pampanga 0601 Kalibo, Aklan 1028 Malaybalay City NATIONAL CAPITAL REGION
REGION 4-A (CALABARZON) 0626 Roxas City 1004 Mambajao, Camiguin 1624 UP Diliman, Quezon City
0429 Antipolo City 0602 San Jose, Antique 1024 Oroquieta City 1622 UP Manila, Manila

THIS FORM IS FREE OF CHARGE AND MAY BE PHOTOCOPIED.

11. ARE YOU A CHILD OF A UP FACULTY OR EMPLOYEE?
Name of parent employed by UP Official Designation College/Unit where employed
2 No 1 Yes

A. Category B. Tenure C. Status (Place an X in only one box.)

Full-time Temporary In active service
Part-time (e.g., lecturer, etc.) Permanent On leave with pay
With compensation Contractual On leave without pay
Without compensation Casual On secondment

12. Do you have any PHYSICAL DISABILITY or CONDITION that requires special attention or would make it difficult for you to take a regular test?
2 No 1 Yes (specify)

(for PWDs taking the exam in Diliman, attach Certification of Disability and contact the Director.)

13. PERMANENT HOME ADDRESS

Number and Street . . . . . . . . . . . . . . . . . . . .

Subdivision / Village, Barangay, District . . .

Town / City . . . . . . . . . . . . . . . . . . . . . . . . . . .

Province . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postal/Zip Code

14. CONTACT INFORMATION

Telephone Number . . . . . . . . . . . . . . . . . . . . Cellphone Number

E-mail Address . . . . . . . . . . . . . . . . . . . . . . .

15. SOCIO-ECONOMIC DATA. Furnish ALL the required information for each household member listed. For purposes of this section, HOUSEHOLD is defined as a social unit consisting of a person living alone or
a group of persons who sleep in the same housing unit and have a common arrangement in the preparation and consumption of food. Also included are those who may not be with the group but are blood related and
contribute regularly to household finances, e.g. OFW parent.
NOTE: if the requested information is not applicable, plese leave the space blank.
Household Civil Highest Present SOURCES OF FUNDS in the YEAR 2012 (in Pesos)
Members Name Citizenship Status Educational Occupation Employer Income Pension Financial Total
Attainment Assistance (11)
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) =(8)+(9)+(10)

Applicant

Father

Mother

Sub-Total (a)

Brothers and Sisters

Sub-Total (b)

Other Household Members (those contributing to household finances on a regular basis)

Sub-Total (c)

(1) For each of the Other Household Members, indicate the member's relationship to the student (e.g. grandmother, aunt, uncle, etc.)
(2) Write DECEASED after name of deceased parent. Write down mother's maiden name.
(5) Indicate the highest educational level which each household member actually completed (e.g. Elementary, High School, College Undergraduate, BA, BS, MBA or PhD).
(8) INCOME includes wages and salaries, income from business/farm/profession, allowances, and investment income/earnings.
(9) Pension from GSIS, SSS, Provident Fund, or former employer.
(10) Financial assistance includes cash and other forms of financial support from any domestic or foreign source (e.g. relatives, friends, NGOs, LGUs), including scholarships and educational plans.

NOTE: If your annual family gross income is equal to or less than P 100,000, please attach a photocopy of your FAMILY'S 2012 income tax returns or BIR certification/s.

I certify that:
I affirm that:
(1) I have read all the information contained in the General Information Bulletin on Freshman Admission for (1) the information which my son/daughter/dependent has
Academic Year 2014-2015 and understood all the instructions in connection with my application for the UPCAT; provided in this application form is true, complete,
(2) All the information supplied in this application form are true, complete, and accurate; and accurate.
(3) I have not taken the UPCAT previously and that I am not taking nor have I taken any college subject in (2) I have read all information contained in the General
any school, college or university; and Information Bulletin on Freshman Admission Academic
(4) I will abide by the University rules and policies on test administration and on student fees including Year 2014-2015 and agree to abide by the University
tuition, scholarships, and financial assistance programs. rules and policies on student fees including tuition,
scholarships, and financial assistance programs.
I am aware that any or all the information furnished in this application may be checked against the original
documents and that withholding information or giving false information will disqualify me from admission/will I recognize that in signing this application form, I share with
be a basis for dismissal, if admitted. I also understand that no results for my application may be released my son/daughter/dependent the responsibility for the veracity
until all requirements are satisfied. and completeness of the information supplied herein.

Furthermore, I understand that all information I provide in this form as well as during the UPCAT may be used
by the University for research and I consent to such with the assurance that my personal details will be kept
secure.

SIGNATURE OF STUDENT SIGNATURE OF PARENT/GUARDIAN

DATE DATE

REMINDERS:
No results may be released pending submission of all requirements stipulated in UPCAT Form 2 (Secondary School Record). Form 2 must be accomplished accurately and
completely by the Office of the Principal/School Head. Specifically, check that: (a) final grades for all subjects taken are complete and accurate; (b) failing grades (if any) are also included;
(c) the number of units for each subject is indicated; (d) the principal's signature is across the photograph and at the bottom of both pages of the form; (e) erasures and corrections have been
initialed by the principal; (f) school dry seal (if any) is affixed; (g) your signature is on the space indicated; and (h) a Certified True Copy of the certificate of Government Recognition or
Government Permit of each private school attended is submitted.

REMEMBER TO CLIP ON YOUR APPLICATION FORM TWO ADDITIONAL IDENTICAL RECENT PHOTOGRAPHS FOR YOUR TEST PERMIT. THEY SHOULD BE
IDENTICAL TO THE ONES YOU ATTACHED ON THE FRONT PAGE AND ON UPCAT FORM 2 (SECONDARY SCHOOL RECORD). DO NOT PASTE THE PHOTOGRAPHS.
EACH PHOTOGRAPH SHOULD HAVE YOUR PRINTED NAME AT THE BACK.