PUPSHS-RASForm-2017-0004-0323

PUP SENIOR HIGH SCHOOL ROUTE AND APPROVAL SLIP

ACADEMIC YEAR 2017-2018

(To be accomplished by the Enrolling Officer. Please write legibly)

Name of Applicant: _C__A__N__T__O__N__J_O___S_,__S__H__A__R__M__A__I_N__E___K__H__A__T__T_E___P__E__Ñ__A____________________________________

Reference Number: _2_0__1_7__-_0_0__0_4__-_0_3__2__3_____________ Schedule of Enrollment: _M__A__Y___1_0___2_0__1_7____1_:_3__0_P__M___________

Name of Junior High School: _P_O__L__Y_T_E__C_H__N__IC__U__N__IV__E_R__S_I_T_Y__O__F__T_H__E__P_H__I_L_I_P_P__IN__E_S__,_L_A__B__O_R__A_T__O_R__Y__H__IG__H__S__C_H__O__O_L

(If this document contains random and unreadable text, open and print this page using another computer and/or printer)

Enrollment is on a FIRST-COME-FIRST-SERVED BASIS and SUBJECT TO THE AVAILABILITY OF SLOTS. The application for admission

and enrollment shall be processed and approved only upon compliance to the following requirements:

Step 1: Admission Services (SHS) Remarks: Year Graduated:__2_0_1_7____

Processed by: HS English__8_8_._5___ HS Math__8_2_____ HS Sci _9__0_____ HSGWA_9__0_._6_6___

Admission Status:
____ Laboratory High School

____ Senior High School, pls. specify track/strand :_S_H__S_A__B_M______

__________________________ LRN: _4__8__2_0__9_6__1_5__0__1_1__9________________________________
Signature over Printed Name
Requirements: ____ Has DepEd Qualified Voucher Recipient Certificate
___2 copies of 2 x 2 picture with nameplate ____ Education Service Contracting (ESC) Grantee
___Original Form 138
___NCAE original Remarks: Uploaded Photo
___PSA original Birth Certificate
___Original Certificate of Good Moral Character Remarks:
___Photocopy of Certificate of Completion
___Long brown envelope
___Chest X-ray with film
___Photocopy of Baptismal Certificate
___Photocopy of Grade 10 school ID
___DepEd Qualified Voucher Recipient Certificate or ESC
Grantee Certificate (strictly required to those coming
from the private school)

Step 1.A Registration of student

Administered by: ______________________ _______ Date:
Signature over printed name Date Remarks:

Step 2: MEDICAL CLINIC (East Wing Ground Floor)

Examined by:

__________________________ Date:
Signature over Printed Name

Step 3: RETURN THIS FORM TO SHS OFFICE for the
submission of documents

Processed by:

__________________________
Signature over Printed Name

Your admission in the University is valid and official if you have complied with all of the admission requirements and have been
acknowledged by the Registrar’s Office. No Student will be allowed to attend classes without the Registration Certificate

PUP SENIOR HIGH SCHOOL CONFIRMATION SLIP OF ENROLLMENT

Name of Applicant: _C__A__N__T__O__N__J_O___S_,__S__H__A__R__M__A__I_N__E___K__H__A__T__T_E___P__E__Ñ__A____________________________________
Reference Number: _2_0__1_7__-_0_0__0_4__-_0_3__2__3_____________ Schedule of Enrollment: _M__A__Y___1_0___2_0__1_7____1_:_3__0_P__M___________

Name of Junior High School: _P_O__L__Y_T_E__C_H__N__IC__U__N__IV__E_R__S_I_T_Y__O__F__T_H__E__P_H__I_L_I_P_P__IN__E_S__,_L_A__B__O_R__A_T__O_R__Y__H__IG__H__S__C_H__O__O_L

Senior High School, pls. specify track/strand: _S_H__S_A__B_M____ Received by: ________________________

(Signature over Printed Name)

Date: ________________________

THIS FORM IS NOT FOR SALE. Please be informed that the tuition fee is free for those with DepEd Qualified Voucher Recipient Certificate.
If you encountered suspicious person that required you to pay them for the processing of students in the PUPSHS,
PLEASE INFORM THE PUPSHS DEPARTMENT IMMEDIATELY.

REPUBLIC OF THE PHILIPPINES )

CITY OF MANILA ) S.S. FORM 1

CERTIFICATION UNDER OATH

I, _______________________________________________________________________________, of legal age,
Filipino, with residence and postal address at ___________________________________________
_____________________________________________________________________________________________
after having been duly sworn to in accordance with the law, do hereby depose and say THAT:

1. I am an enrollee of Polytechnic University of the Philippines (PUP), (Please check one:
Sta. Mesa Manila / Quezon City / San Juan) under its Senior High School

Program;
2. In compliance with the documentary requirements of the aforementioned University,

among others, I am submitting the following documents:
a.) Form 138; b.) Birth Certificate; c.) National Career Assesment and Examination; d.)
Certificate of Good Moral Character; e.) Certificate of Completion; and e.) QVR Certificate
(Senior High School Voucher from DepEd).
3. I vouch the authenticity and genuineness of the documents I submitted to PUP;
4. I undertake and assume full and complete responsibility for all the consequences which
may arise in case the any of the documents I submitted is found to have been falsified or
fabricated;
5. I understand that my admission is merely provisional and that the University reserves its
right to deny my application for enrollment or revoke my enrolment 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.
6. I am executing this Certification Under Oath in order for the University to proceed with
my enrollment.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of _______, 2017 at
Sta. Mesa, Manila.

______________________________

AFFIANT

SUBSCRIBED AND SWORN to before me this__________ day of ___________ at
______________________________________, _________________, Philippines, affiant exhibiting to me
his/her_________________________ as proof of his/her identity.

Doc. No. __________
Page No. __________
Book No.__________
Series of 2017

REPUBLIC OF THE PHILIPPINES )

CITY OF MANILA ) S.S. FORM 2

CERTIFICATION UNDER OATH

I, __________________________________________________________________________________, a minor,
with the concurrence of _____________________________________________________________ Filipino,
with residence and postal address at_________________________________________________________
____________________________________________________________________________________________
after having been duly sworn to in accordance with the law, do hereby depose and say THAT:

1. I am an enrollee of Polytechnic University of the Philippines (PUP), (Please check one:
Sta. Mesa Manila / Quezon City / San Juan) under its Senior High School

Program;
2. In compliance with the documentary requirements of the aforementioned University,

among others, I am submitting the following documents:
a.) Form 138; b.) Birth Certificate; c.) National Career Assesment and Examination; d.)
Certificate of Good Moral Character; e.) Certificate of Completion; and e.) QVR Certificate
(Senior High School Voucher from DepEd).
3. I vouch the authenticity and genuineness of the documents I submitted to PUP;
4. I undertake and assume full and complete responsibility for all the consequences which
may arise in case the any of the documents I submitted is found to have been falsified or
fabricated;
5. I understand that my admission is merely provisional and that the University reserves its
right to deny my application for enrollment or revoke my enrolment 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.
6. I am executing this Certification Under Oath in order for the University to proceed with
my enrollment.

IN WITNESS WHEREOF, I have hereunto set my hand this _______ day of _______, 2017 at
Sta. Mesa, Manila.

______________________________

AFFIANT

With my conformity:

_______________________________

SUBSCRIBED AND SWORN to before me this__________ day of ___________ at
______________________________________, _________________, Philippines, affiant exhibiting to me
his/her_________________________ as proof of his/her identity.

Doc. No. __________
Page No. __________
Book No.__________
Series of 2017