REPUBLIC OF THE PHILIPPINES Reference Number:

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES 2021-0003-4173

OFFICE OF THE UNIVERSITY REGISTRAR
ADMISSION AND REGISTRATION SERVICES
STA. MESA, MANILA Selected NSTP:

SAR-FORM 1 CWTS
WITH CONFIRMATION DOCUMENTS

Confirmation Slip (For a 4 or 5-year degree, or 3-year diploma

program)

The University Admission Committee,

Attach
I am RAPHAEL ANDREI RANCE BALUYUT , recent 2x2" photo
(Name) Here
graduated in 2021
from _UNIVERSITY OF THE EAST CALOOCAN
would like to confirm my interest to be admitted and enrolled this First Semester, Academic Year 2021-2022 in a program where I am qualified
based on the Specific College Criteria.

BACHELOR OF SCIENCE IN BUSINESS ADMINISTRATION MAJOR IN FINANCIAL MANAGEMENT (BSBAFM)

Respectfully yours,

RAPHAEL ANDREI RANCE B_ ALUYUT

_
Signature over Printed Name of Applicant Note: Read carefully the freshman admission and enrollment procedure

This form contains personal-identifiable information that is subject to Data Privacy

Please keep this form protected and in a safe place


REPUBLIC OF THE PHILIPPINES Reference Number:
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES 2021-0003-4173
OFFICE OF THE UNIVERSITY REGISTRAR
ADMISSION AND REGISTRATION SERVICES
STA. MESA, MANILA Selected NSTP:

SAR-FORM 1
CWTS

WITH CONFIRMATION DOCUMENTS

Confirmation Slip (For a 4 or 5-year degree, or 3-year diploma

program)

The University Admission Committee,

Attach
I am RAPHAEL ANDREI RANCE BALUYUT , recent 2x2" photo
(Name) Here
graduated in 2021
from _ UNIVERSITY OF THE EAST CALOOCAN
would like to confirm my interest to be admitted and enrolled this First Semester, Academic Year 2021-2022 in a program where I am qualified
based on the Specific College Criteria.

BACHELOR OF SCIENCE IN BUSINESS ADMINISTRATION MAJOR IN FINANCIAL MANAGEMENT (BSBAFM)

Respectfully yours,

RAPHAEL ANDREI RANCE B_ ALUYUT

_
Signature over Printed Name of Applicant Note: Read carefully the freshman admission and enrollment procedure
This form contains personal-identifiable information that is subject to Data Privacy
Please keep this form protected and in a safe place
 FRESHMAN ADMISSION AND ENROLLMENT
PROCEDURE
ACADEMIC YEAR 2021-2022

Name of Applicant: RAPHAEL A_ NDREI R_ ANCE BALUYUT

Reference Number: 2021-0003-4173 Date of Confirmation: _Thursday, September 23, 2_021

SHS ABM
Track/Strand:
Note: Read carefully the Freshman Admission and Enrollment Procedure
1. Online Confirmation
1.1. Download this Confirmation Slip. Non-confirmation on the prescribed period would mean forfeiture of your slot.
1.2. Submit the following documents upon enrollment:
1.2.1. Required Credentials:
Upon confirmation, enrollee must submit the original copy and photocopies of the following documents to the Admission
and Registration Services Section on or before September 30, 2021 personally or thru courier:

PUP Admission and Registration Services For further inquiries, clarifications, or in case of
G/F Room 117 West Wing Main error, email admission.main@pup.edu.ph
Building Anonas St., Brgy 630, Sta. Mesa, with Message Subject: Freshman Online
Enrollment – Sta. Mesa Manila
Manila 1016

1.2.1.1 For Graduates of Senior High School AY 2020-2021

a) Original or certified true copy of grade 10 & 11 high school card.
b) Original Senior High School Card (F138) with school dry seal.
c) Original PSA Birth Certificate.
d) Certification of Good Moral issued by the SHS Principal/or Guidance Counselor with school dry seal.
e) Duly signed Waiver/Certification Under Oath. (Waiver is attached in this Confirmation Slip)
f) PUP Medical Health Information Sheet for Student. Do not leave any item unanswered and send to
medical@pup.edu.ph
g) Two (2) pcs of 2x2 inches colored picture with white background and with the applicant's name on the
photo.
h) One (1) pc. long brown envelope

1.2.1.2 For Previous Senior High School Graduates/High School Graduates of Past School Year/s
In addition to the above admission requirements:
i) Certification from the respective senior high school registrar with school dry seal and noted by the Principal
that no copy of F137A has been sent to other college or university.
j) Notarized certification of non-enrollment for high school/senior high school graduates that they have
not enrolled in any technical/diploma/degree program immediately after graduation by the SHS
Principal.
k) Notarized Waiver that if there is concealment of previous enrollment, PUP enrollment becomes null and
void.

1.2.1.3 For Graduates of Alternative Learning System

a. Certificate of Completion
b. Certificate of Rating
c. Verified/Certified True Copy of National List of Passers which shows the name of the applicant
d. Certificate of Good Moral Character issued by the school last attended
e. PSA Birth Certificate
f. Two (2) pcs of 2x2 inches colored picture with white background and with the applicant's name on the
photo.
g. One (1) pc. long brown envelope

2. Downloading and Printing of Registration Card

Wait for further announcement via PUP social media accounts on how to download your Registration Certificate as proof of
your official enrollment in PUP.

These documents contain personal-identifiable information that is subject to Data Privacy.

Please keep these documents protected and in a safe place.
 Republic of the Philippines
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES
Office of the Vice President for Administration
MEDICAL SERVICES DEPARTMENT

HEALTH INFORMATION SHEET FOR STUDENT

Do not leave any item unanswered. Print, accomplish, sign, scan, and send this Health Information Sheet to medical@pup.edu.ph
PART I. STUDENT INFORMATION
Name: Date:
Address: School Year: Age:
Sex: Civil Status: Course / College:
Blood Type
Parent's Name /Guardian:
Landline: Cellphone:

PART II. MEDICAL HISTORY

1. Do you need medical attention or has known medical illness? ⬜ No ⬜ Yes
(Please check the following that apply and give more information as needed)
⬜ Asthma ⬜ Fainting ⬜ Vision Problems ⬜ Hearing Problems
⬜ Diabetes ⬜ Heart Condition ⬜ Kidney Disease ⬜ Hearing Problems
⬜ Seizure Disorder ⬜ Hyperventilation ⬜ Hemophilia ⬜ Muscle Weakness/Paralysis
⬜ Migraine ⬜ Hypertension
⬜ Others (Pls. Indicate):

2.Previous Hospitalization: ⬜ No ⬜ Year:

Yes
Operation/Surgery: ⬜ No ⬜ Year:
Yes

3. Additional Information for Students with Medical Conditions:

As a Parent/Guardian, I would like to declare that my child/ward had history of allergies to the following:
Food:
Medicines:

PART III. FAMILY HISTORY

⬜ Diabetes ⬜ PTB ⬜ Hypertension ⬜ Cancer
⬜ Others (Pls. Indicate):

PART IV. PERSONAL HISTORY

Cigarette Smoking: ⬜ Yes ⬜ No
Alcohol Drinking: ⬜ Yes ⬜ No
Do you feel stressed: ⬜ Yes ⬜ No

I hereby state to the best of my knowledge, my answers to the above questions are complete and correct.

By affixing my signature (Parent/Guardian), I am agreeing to the PUP Data Privacy Policy and giving my
consent in the collection and processing of the student's name above his/her Personal Information in
accordance thereto and be given medical and dental care by the PUP physician/Dentist.

Signature of Parent/Guardian Signature of Student Date

Due to Community Quarantine, please be informed that Physical Examination for enrollment and submission
of chest x-ray is temporarily deferred until further notice.
 ver. 2021
CERTIFICATION/UNDERTAKING

I, , of legal age, Filipino, with residence and postal

address at ,
hereby certify THAT:
1. I am an enrollee of Polytechnic University of the Philippines
(PUP), (Please check one: ▢ Sta. Mesa, Manila
▢ Branch/Campus:
(State the Branch/Campus)
2. In compliance with the documentary requirements of the aforementioned University, among
others, I am submitting/undertake to submit the following documents on or before September
30, 2021:
a. Original or certified true copy of grade 10 & 11 high school card.
b. Original Senior High School Card (F138) with school dry seal.
c. Notarized certification of non-enrollment for high school/senior high school graduates
who have not enrolled in any technical/diploma/degree program immediately after
graduation.
d. Original PSA Birth Certificate.
e. Certificate of Good Moral issued by the SHS Principal/or Guidance Counselor with school
dry seal.
f. Duly signed Certification Under Oath, Form 2
g. Two (2) pcs. 2 in. x 2 in. colored picture with white background with applicant's name
on the photo.
h. One (1) pc. long brown envelope.
For Senior High School Graduates/High School Graduates of Past School Year/s
In addition to the above admission requirements:
a. Certification from senior high school registrar with school dry seal and noted by the
Principal that no copy of F137A has been sent to other college or university.
b. Notarized certification of non-enrollment for senior high school graduates who have
not enrolled in any technical/diploma/degree program immediately after graduation
with "waiver" that if there is concealment of previous enrollment, PUP enrollment
becomes null and void.
For Graduates of Alternative Learning System
h. Certificate of Completion
i. Certificate of Rating
j. Verified/Certified True Copy of National List of Passers which shows the name of the
applicant
k. Certificate of Good Moral Character issued by the school last attended
l. PSA Birth Certificate
m. Two (2) pcs of 2x2 inches colored picture with white background and with the applicant's
name on the photo.
n. One (1) pc. long brown envelope
3. I vouch the authenticity and genuineness of the documents I submitted/will submit to PUP;
4. I undertake and assume full and complete responsibility for all the consequences which may
arise in case any of the documents I submitted is found to have been falsified or
fabricated;
5. I vouch that I have not enrolled in any Higher Education Institution including any branch or
campus of PUP otherwise my enrollment will be cancelled.
6. I understand that my admission is merely provisional and that the University reserves its right to
deny my application for enrollment or revoke my enrollment should the information I
declared or documents submitted have been found to be deceitful, fabricated and falsified
without prejudice to filing a criminal case against me; and
7. I am executing this Undertaking in order for the University to proceed with my enrollment.

Signature above Printed Name of

Parent/Guardian
ATTESTED by:

_________________________
Signature above Printed
Name of Enrollee Date:
__________________