Republic of the Philippines
PALOMPON INSTITUTE OF TECHNOLOGY
Palompon, Leyte
GUIDANCE CENTER
Tel. No. (053) 555 - 8458
Examinee No. : 20201580526438897
APPLICATION FORM
COLLEGE ENTRANCE EXAMINATION 2x2 colored ID Picture with
SY __2019-2020__ nametag
(Lastname, Firstname,
Middlename)
ACADEMIC STATUS OF APPLICANT
Currently enrolled as Grade 12 Student
A Senior High School Graduate
A High School Graduate of the old curriculum (BEC)
Alternative Learning System (ALS) Passer
Phillippine Educational Placement Test (PEPT) Passer
Second (2nd) Courser
Transferee
Returnee
Others
BACKGROUND INFORMATION
Last Name BAJEN
First Name MICHAEL JAN
Middle Name ABIERTAS
Sex: Male Female Nationality: __FILIPINO__
Contact Information
Permanent Home Address: BRGY. BUSCADA BASEY SAMAR Zip Code: 6720
House No., Street, Barangay City/Municipality Province
Telephone/Cell phone No.: 09751539651 Email Address (if available): bajenmichaeljan3@gmail.com
SCHOOL ATTENDED (Where you last attended/are currently completing secondary level education)
Name of School: Aclc College - Tacloban
Complete Address: Tacloban City
Degree/Course Attained (for transferee/second courser): N/A
Senior High School Track (for SHS graduate):
PROGRAM APPLYING FOR
1st Choice: Bachelor of Science in Marine Transportation 2nd Choice: Bachelor of Science in Marine Engineering
SHS Graduate for Freshmen (College) Grade Requirements
Original and Photocopy of Certi ed True Copy of Grade 11 and Grade
Maritime Courses:
12 as of the First Semester Report Card (Form 138)
80% GWA/GPA
Certi cation of Enrollment (for currently enrolled applicants)
80% average grade for English
3 pcs. recent 2x2 ID picture (colored background, with SURNAME,
80% average grade for Math
FIRST NAME, MIDDLE NAME nametag and wearing decent attire)
80% average grade for Science
Original and Photocopy of Birth Certi cate - PSA authenticated
2.5 GWA for Transferees/Shifter/Second Coursers
Properly lled-out application form with Data Privacy Consent
Examination Permit
Education Courses:
Transferees, Shifters and Second Coursers (College) 85% GWA/GPA/Rating
2.0 GWA for Transferees/Shifter/Second Coursers
Original and Photocopy of Certi ed True Copy of Transcript of
Records/Report of Rating duly signed by an authorized o cial (for
Other Courses:
currently enrolled applicants)
Certi cation of Enrollment (for currently enrolled applicants) 80% GWA/GPA
3 pcs. recent 2x2 ID picture (colored background, with SURNAME, 2.5 GWA for Transferees/Shifter/Second Coursers
FIRST NAME, MIDDLE NAME nametag and wearing decent attire)
Original and Photocopy of Birth Certi cate - PSA authenticated
Properly lled-out application form with Data Privacy Consent
Examination Permit
Data Privacy Consent
The Palompon Institute of Technology is collecting personal information for the purpose of:
Facilitating admission to the Institute
Determining eligibility for the program applied
Transmittal of data internally to other o ces/unit entities for any legitimate purpose
Data sharing to other government agencies who has mandates for processing student personal data (ex. Commission on Higher Education, TESDA, etc.)
Other legitimate requests for data processing which the student will be noti ed and asked for separate consent
I hereby certify that all information supplied in this application form are true, complete and accurate. I understand that any false or
incomplete entry may cause my disquali cation for admission.
I have read and understood the Institute's Data Privacy Statement and express my consent for the Palompon Institute of Technology to
collect, record, organize, update or modify, retrieve, use, consolidate, block, erase or destroy my personal data.
I hereby a rm my right to be informed, object to processing, access and rectify, suspend or withdraw my personal data, and be
indemni ed in case of damages pursuant to the provisions of the Republic Act No. 10173 of the Philippines or Data Privacy Act of 2012 and its
corresponding Implementing Rules and Regulations.
__________________________________________ ____________________
Signature over Printed Name Date
PIT Vision:
A Premier Polytechnic State University
PIT Mission:
To strengthens its capacity of producing higly skilled, competent, and world-class human resources, responsible to ful ll stakeholder needs, goals of the
national development and ASEAN integration, for the attainment of a good quality of life with the guidance and providence of God.
