Applicant ID:
Personal Information
Picture
Instruction:
Kindly type ‘NA’ in boxes where there are no possible answers to the information
being requested.
Classified as: □Freshman □Cross Enrollee □Transferee □Exchange Student □Second Courser
□Degree Holder Mode of Payment: □Full Payment □Installment
PERSONAL DATA
Name:
Last Name First Name Middle Name Extension Name
Program:
(Program offerings listed in the last page)
Date of Birth: Age: Place of Birth: Civil Status:
Country: Nationality: Nationality *for dual citizen:
Religion: Gender: □ Male □ Female □Preference (Check if applicable) Non Binary (LGBT)
Mobile Number: Email address:
Height (in feet and inches): Weight (in pounds): Blood Type:
Learner’s Reference Number (LRN): QVR: ESC:
Permanent address:
Region Province Municipality
Zip Code:
(Rm# Bldg./House#, Street, Brgy.)
Residential Tel No.:
Provincial Address:
Region Province Municipality
Zip Code:
(Rm# Bldg./House#, Street, Brgy.)
Residential Tel No.:
FAMILY DATA
Father’s Name: Email Address:
Occupation: □ Business/Entrepreneur/self-employed □ □
OFW (land/or sea) Government Employee □ Others, please specify
□ Employee (Private company)
□ Retired
□ Deceased
Contact Number: □ LPU Alumni □ Current LPU Employee
Mother’s Maiden Name: Email Address:
Occupation: □ Business/Entrepreneur/self-employed □ OFW (land/or sea) □ Government Employee □ Others, please specify ______________
□ Employee (Private company) □ Retired □ Deceased
Contact Number: ____________________ □ LPU Alumni □ Current LPU Employee
Parent’s Home Address: ___________________________________No. of Brothers: ________ No. of Sisters: ________
Parent Status:
□ Married □ Single Parent □ Not Married □ Other, please specify _______________________________________________________________
Living arrangement:
□ With Parents □ With Relatives □ With Guardian □ Living in Dormitory/Apartment □ Living in Dormitory/Apartment □ Living with spouse
□ Other, please specify _______________________________________________________
If married, name of spouse: ________________________ Occupation: ________________ No. of Children: _______
Who’s Financing your Education:
□ Parents □ Educational plan □ Self-Supporting / Working
□ Relatives □ Scholarship/Grant □ Others, please specify __________________________________________________________
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
Guardian’s Name: _______________________________ Relationship: ________________________________
Home Tel. No.: _________________________________ Office Tel. No.: _______________________________
Address: ______________________________________ Mobile No.: __________________________________
EDUCATIONAL DATA
To be Filled Out by Senior High School Applicants
Name of Junior High School: __________________________________________________________________
□
School Type: Private Public □ Year Attended: From ______ to _____
School Address: _______________________________________ Email Address: ________________________
Highest Honor/Award Received: __________________________________________ General Average: ____
To be Filled Out by First Year College Applicants
Name of Senior High School: __________________________________________________________________
□
School Type: Private Public □ Year Attended: From ______ to _____
School Address: _______________________________________ Email Address: ________________________
Track: Academic-
□ ABM □ HUMSS □
STEM □ General Academic □ Pre-Baccalaureate Maritime
□ Others, please specify _____________________________________
Technical-Vocational-Livelihood-
□ Agri-Fishery □ Home Economics □ ICT □ Industrial Arts □ TVL Maritime
□ Sports Track □ Arts and Design Track □ Others, please specify _____________________________________
Highest Honor/Award Received: __________________________________________ General Average: ____
To be Filled Out by Transferees, College of Law, and Graduate School Applicants
Name of College/University: __________________________________________________________________
School Address: _______________________________________ Email Address: ________________________
□
School Type: Private Public□ Year Attended: From ______ to _____
Program/Course: __________________________________________________________________________
Highest Honor/Award Received: __________________________________________ General Average: ____
FOR FOREIGN STUDENTS ONLY
Passport No.: _______________________________ Type of Visa: ___________________________________
Date Issued: ________________ Place Issued: ____________________ Visa Status: ____________________
I-Card No.: ____________________________ Authorized stay from: ______________ to _________________
Remarks: _________________________________________________________________________________
TERMS OF REFERENCE:
I hereby attest to the completeness and accuracy of all information supplied in this form. I understand that
withholding of information or giving false information may nullify my application for admissions or may jeopardize
my continued stay after admission has been granted.
The University will use the information that you provide to us and information we collect about you to administer
your application and will serve permanent data upon enrollment. In addition, we may use your information to
analyze and improve our admissions process, use your contact details, demographic information and other details
to contact you with news, marketing or promotional information regarding LPU and studies/surveys to be
conducted by LPU via phone calls, mail, email, SMS or any type of electronic facility; and for other University
processes and functions. We also might use your information to conduct general research. We may use your
information and share it internally with other University offices and units. Please refer to the link of LPU Data
Privacy Policy Terms and Conditions.
I agree with the terms of references
________________________________________________ __________________________________________________________
Student signature over printed name/Date Parent or Guardian Signature over printed name if minor/Date
Note: Please attach a copy of any of valid IDs of Parent/Guardian.
Lyceum of the Philippines University
Intramuros, Manila
Student Records Management Department
(Office of the University Registrar)
RECORDS AND HEALTH WAIVER
This is to state that I will submit the original copies of the following admission requirements on or before
September 30, 2022:
Senior High School Grade 11: College Freshman:
1. F138 (Original Grade 10 Report Card) 1. F138 (Original Grade 12 Report Card)
2. Certificate of Good Moral Character 2. Certificate of Good Moral Character
3. ESC/QVR Certificate 3. Copy of PSA Birth Certificate
4. Copy of PSA Birth Certificate 4. 1 pc. 2x2 Colored Picture
5. 1 pc. 2x2 Colored ID Picture
Senior High School Transferee: College Transferee:
1. F138 (Original Grade 11 Report Card) 1. Honorable Dismissal / Transfer Credentials
2. Certificate of Good Moral Character 2. True Copy of Grades / Transcript of Records
3. ESC/QVR Certificate 3. Certificate of Good Moral Character
4. Copy of PSA Birth Certificate 4. Course Description (if Available)
5. 1 pc. 2x2 Colored ID Picture 5. Copy of PSA Birth Certificate
5. 1 pc. 2x2 Colored ID Picture
I understand that will not be allowed to enroll next semester if I fail to submit the requirements stated. Also, I will
only use and submit my credentials to LPU and will not forward them to any other institution with the intent to
enroll.
Furthermore, I understand that I have to undergo physical/medical examination as a requirement of my program.
For CITHM Students only: In case I fail in the Hepa B screening, I shall shift to a non-CITHM program in LPU as
soon as possible.
I hereby acknowledge that I have carefully read this waiver, understood its contents and will abide by the rules and
regulations of LPU pertaining to enrollment.
__________________________________________
Signature Over Printed Name of Student
With my conformity:
______________________________________ __________________________________
Printed Name and Signature of Parent/Guardian Date Filed
