VALID FOR PLV CAT 2019 ONLY

PAMANTASAN NG LUNGSOD NG VALENZUELA Application No.

COLLEGE ADMISSION TEST APPLICATION FORM

Examination Room Assignment / Time:

INSTRUCTIONS: READ APPLICATION REQUIREMENTS BELOW. DO NOT APPLY IF NOT QUALIFIED. Fill in all the required information legibly. DO NOT leave an item blank.
If item is not applicable, indicate “N/A”. Place “X” mark in appropriate boxes. Only fully accomplished forms will be accepted. Credentials led in support
of this application will become the property of this institution and will not be returned to the applicant.

A. NAME OF APPLICANT as it appears on the Birth Certificate

(Place one letter in each box and leave one box blank between names)

Last Name S U R I O

First Name M A R Y R O S E Name Extension N / A

Middle Name S U R I O
B. FACTS OF BIRTH
Citizenship Gender Date of Birth (MM / DD / YYYY) Place of Birth (City, Municipality / Province)
Male Female
FILIPINO 06 10 2001 QUEZON CITY
Father’s Name (Last Name, First Name, Name Extension, Middle Name) Mother’s Maiden Name (Last Name, First Name, Name Extension, Middle Name)
SURIO,NONILON SURIO, ROSIE FLORES
C. CURRENT DEMOGRAPHIC DATA
Address House / Room / Floor / Block / Lot / Phase No. Street Name Subdivision

30 3RD SAN DIEGO

Barangay City / Municipality District Zip Code Height (Meters) Weight (Kilos)

MAYSAN VALENZUELA CITY 1 2 N/A

1440 1.62 48
E-mail Address Telephone Number
Mobile Number
Maryrosesurio@yahoo.com
0 9 2 8 9 1 8 2 7 6 4
D. EDUCATIONAL BACKGROUND
Name of Last School Attended (Do Not Abbreviate) Section Year Graduated (If Applicable)

PAMANTASAN NG LUNGSOD NG VALENZUELA GAS 12-1 2019

School Address Region School Classification

POBLACION II, MALINTA, VALENZUELA CITY NCR Public Private Other/s:

E. INTENDED COURSE G. REQUIREMENTS EVALUATION

(To be accomplished by the PLV Of ce for Admissions)
FIRST CHOICE (Course/Major):
Bachelor of Secondary Education major in Mathematics APPLICATION REQUIREMENTS
SECOND CHOICE (Course/Major): 1. Certified True Copy of Grade 11 (1st and 2nd Semester
Bachelor of Science in Accountancy School Year 2017-2018 report card with GWA of 83% and above.

2. Certified True Copy of Grade 12 report card for the recent Grading Period
UNDERGRADUATE DEGREE PROGRAMS OFFERED (School Year 2018-2019) with no grade lower than 80% per subject during
• COLLEGE OF BUSINESS, ACCOUNTANCY AND PUBLIC ADMINISTRATION the time of application.
1. Bachelor of Science in Accountancy (BSA)
2. Bachelor of Science in Business Administration major in Financial Management (BSBA-FM) 3. Certified True Copy of School ID (Front and Back)
3. Bachelor of Science in Business Administration
major in Human Resource Development Management (BSBA-HRDM)
4. Bachelor of Science in Business Administration major in Marketing Management (BSBA-MM) 4. Photocopy of PSA/NSO Birth Certificate
5. Bachelor of Science in Public Administration (BSPA) (Must be a Filipino Citizen)
• COLLEGE OF EDUCATION 5. Proof of Residency (2018 Voter’s Registration Certificate from the
1. Bachelor of Elementary Education major in Pre-School Education (BEED)
2. Bachelor of Secondary Education major in English (BSED-ENG)
COMELEC that parent or the applicant is a Registered Voter of Valenzuela).
3. Bachelor of Secondary Education major in Filipino (BSED-FIL)
4. Bachelor of Secondary Education major in Mathematics (BSED-MATH) 6. Sketch of Residence (with Valenzuel5a City Hall as starting point).
5. Bachelor of Secondary Education major in Biological Science (BSED-BIOSCI)
6. Bachelor of Secondary Education major in Physical Science (BSED-PHYSCI)
7. Two (2) recent Passport Size ID Pictures with the following specifications:
• COLLEGE OF ARTS & SCIENCES • Colored with white background and computerized name
1. Bachelor of Arts in Communication Studies major in Theater Arts (BACS) (First Name, Middle Initial, Last Name and Extension Name).
2. Bachelor of Science in Psychology (BSP)
3. Bachelor of Science in Social Work (BSSW)
8. Non-Refundable amount of Php 250.00 application and examination fee.
• COLLEGE OF ENGINEERING AND INFORMATION TECHNOLOGY
1. Bachelor of Science in Civil Engineering (BSCE)
2. Bachelor of Science in Electrical Engineering (BSEE)
3. Bachelor of Science in Information Technology (BSIT) Note:
Spaces for Printed Name/Signature
and Right Thumb Mark of applicant
should be left blank. These shall
F. DECLARATION only be accomplished in the presence
of the Requirements Evaluator/Processor.
I declare under oath that I personally accomplished this application form,
and I hereby certify that the information given are true, correct, and complete
statements. Further, I understand that the acceptance and approval of my application
for the examination is based on the aforestated information.

I therefore agree that, in case of post-verification yields information

contrary to what is declared, my application shall be disapproved, and my payment will
be forfeited. I further agree that any misinterpretation made in this document may
cause the invalidation of the result of this examination. Passport Size ID Picture
(3.5 x 4.5 cm) Right Thumbmark
Further, I hereby give my consent to the Pamantasan ng Lungsod ng
Valenzuela that the abovementioned data may form part of its database that can be
used for relevant purposes but may not be limited to profiling and research, and
especially as basis of data-driven decisions of the University.

Signature over Printed Name of Requirement’s Evaluator

Signature over Printed Name of Applicant

THIS FORM IS NOT FOR SALE

(Print Only in 8.5 x 13 Bond Paper)