AO Form 1- Revised 2022 (Effective 1st Sem.

, AY2022-2023)

QUEZON CITY UNIVERSITY

673 Quirino Hi-way, San Bartolome, Novaliches Q.C. 33
2x 2
ID Picture
A D MI S SI O N S O FFI CE White Background

STUDENT APPLICATION FORM

1st SEM, AY: 2023-2024
GENERAL INSTRUCTION: Kindly fill out all the information needed and do not leave any box unmarked. Write N/A in
items not applicable to you. Please use all CAPITAL.
(Print this form back to back on one single sheet of paper)
Date of Application: LRN: 165511100354 Student No.: (to be filled out by the admission officer)
04/22/23
Are you applying as (Please check the appropriate answer)
✔ SHS Graduating this July Track: Academic Strand: Accountancy, Business, and Management
SHS Graduate Track: N/A Strand: N/A
High School Graduate (Year 2015 and below Graduated in HS) ALS Graduate
Transferee, Are you applying for Accreditation of Subjects? Yes No
2nd Degree Course Taker (already a graduate of a Bachelor’s Degree before) Course:
Course applied for: Please choose 3 preferred courses. Rank (1) 1st Choice (2) 2nd Choice (3) 3rd Choice
1 Bachelor of Science in Management Accounting (BSMA) 2 Bachelor of Science in Accountancy (BSA)
Bachelor of Science in Entrepreneurship (BS ENTREP) Bachelor of Early Childhood Education (BECEd)
3 Bachelor of Science in Industrial Engineering (BSIE) Bachelor of Science in Electronics Engineering (BSECE)
Bachelor of Science in Information Technology (BSIT)
Please Rank preferred Campus: Rank (1) 1st Choice (2) 2nd Choice (3) 3rd Choice
2 Batasan Campus 1 San Bartolome Campus 3 San Francisco Campus
Are you presently enrolled? If yes, Name of School Date of Last Day of
San Francisco High School Classes: June 2023

PERSONAL INFORMATION (As indicated in your PSA Birth Certificate. Use your husband’s surname if married)
Last Name: Princesa First Name: Micaella Shane Middle Name: Agustino

Gmail Address: Date of Birth: (mm/dd/yyyy) Gender: Religion: Citizenship: Filipino

12/19/2004
princesa.micaellashane.agustino@ Female Roman
gmail.com Catholic
Contact Number: 09206881438 Place of Birth: Quezon City Civil Status: If Married, Name of Spouse: N/A
Single
Present Address: #128 Sampaguita St., San Roque II, Bagong Pag-asa, Quezon City

Barangay: Bagong Pag-asa City/ Municipality: Quezon City District No. 1 Zip Code: 1105
Do you have a physical/behavioral condition/Disability? Specify
N/A
EDUCATIONAL BACKGROUND
College: (Leave it blank if never enrolled in college)

Address: N/A

Location: QC Non-QC
Public School Private School
Course: N/A Date Graduated: Honors Received with certification: N/A
N/A
Technical Vocational: (Leave it blank if never enrolled in technical vocational courses)

Address: N/A
Location: QC Non-QC
Public School Private School
Course/Year/s Taken: N/A Date Graduated: Honors Received with certification: N/A
N/A
Senior High School Name or High School Name for HS Graduate:

Address: Misamis St., Bago Bantay, Quezon City

Location: ✔ QC Non-QC ✔ Public School Private School
Track/Strand: Accountancy, Section: 12 ABM – Elton Mayo Date Graduated: Honors Received with certification:
Business, and Management N/A With Honors (1st Semester)
AO Form 1- Revised 2022 (Effective 1st Sem., AY2022-2023)

FAMILY BACKGROUND
Father’s Name: Michael P. Princesa Occupation: House Painter Educ’l Attainment: Contact No.: 09166829319
High School
Mother’s Name: Catherine A. Occupation: Housewife Educ’l Attainment: Contact No.: 09123448030
Princesa College
Parent’s Address: #128 Sampaguita St., San Roque II, Bagong Pag-asa, Quezon City

Guardian: Catherine A. Princesa Relationship: Mother Contact No.: 09123448030

Other Family member/s and or relatives enrolled in QCU. Write below.

Name: N/A Relationship: N/A
Name: N/A Relationship: N/A
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
Name: Catherine A. Princesa Relationship: Mother Contact No.: 09123448030

Address: #128 Sampaguita St., San Roque II, Bagong Pag-asa, Quezon City
All information contained in this application is true and correct, I understand that any misrepresentation may cause for denial of admission from Quezon City University.
I allow and give full consent to QCU to collect and evaluate the above-mentioned information that I declare for legitimate purposes.
PLEASE NOTIFY THE OFFICE OF THE
ADMISSIONS ABOUT ANY CHANGES IN THE
ABOVE INFORMATION Signature of Student over Printed Name Date Signed
Documents / Requirements Verified by: Approved by

Department: Admission Staff Dean / Program Chair

Approved for Admission by:

ANNIE LOU M. GONZALES

Chief, Admission Services

REQUIREMENTS TO BE SUBMITTED at the ADMISSIONS OFFICE ONCE QUALIFIED

FOR QCU ENROLLMENT
FRESHMAN TRANSFEREE
1. Printed (back to back on one single sheet of paper) 1. Printed (back to back on one single sheet of paper)
Fully Accomplished QCU Admission Application Form with 2x2 colored Fully Accomplished QCU Admission Application Form with 2x2
picture white background with name tag and student’s signature at the back colored picture white background with name tag and student’s
on the space below the form. (2sets) signature at the back on the space below the form. (2sets)
2. Original SF9 (Certified True Copy of Grade 11 & Original Grade 12) Form 2. Transcript of Records (For Evaluation Purposes) with General
138- High School Report Card Weighted Average (GWA) of the last semester attended.
Alternative Learning System Certificate of Rating if ALS passer
3. Original PSA Birth Certificate
4. Original Certificate of Good Moral Character 3. Original PSA Birth Certificate
4. Original Certificate of Good Moral Character
5. Original – Recent Brgy. Certificate of Residency
5. Original – Recent Brgy. Certificate of Residency
6. Two(2) 2x2 colored pictures (White Background with Name Tag)
6. Two (2) 2x2 pictures (White Background with Name Tag)
7. Photocopy Senior High School / High School / ALS Diploma (present original)
8. Medical Clearance – Issued by the Medical and Dental Services 7. Original Certificate of Transfer Credentials (CTC)

Additional Requirements for the following Applicants: 8. Medical Clearance – Issued by the Medical and Dental Services
 If with discrepancy between PSA Birth Certificate and School Record – Additional Requirements for the following Applicants:
Affidavit of the Same Person  For Accreditation of Subjects during enrollment period – Subject
 If currently employed - Original Latest Certificate of Employment Course Description of all passed subjects, TOR Copy for QCU and
 If Married Female Student - Original Marriage Certificate NSTP 2 Serial Number (Secure request letter from QCU Admissions
 Applicants from schools with non-numerical (Pass/Fail) grades- Certificate of Office)
Non-issuance of Numerical Grades (Issued by the School Registrar)  If with discrepancy between PSA Birth Certificate and School
 In cases where the student-applicant cannot reasonably secure his/her school Record – Affidavit of the Same Person
credentials for reasons beyond his/her control, such as: Closure of the school  If currently employed - Original Latest Certificate of Employment
last attended and Damage of documents due to fire or natural calamities -  If Married Female Student - Original Marriage Certificate
Certificate of eligibility for admission to college from the Commission on  Applicants from schools with non-numerical (Pass/Fail) grades-
Higher Education (CHED) Certificate of Non-issuance of Numerical Grades (Issued by the
 Applicants who stopped for 1 Yr or more - Affidavit of Non-Enrollment from School Registrar)
other Universities  In cases where the student-applicant cannot reasonably secure his/her
school credentials for reasons beyond his/her control, such as:
Closure of the school last attended and Damage of documents due to
fire or natural calamities - Certificate of eligibility for admission to
college from the Commission on Higher Education (CHED)
 Applicants who stopped for 1 Yr. or more - Affidavit of Non-
Enrollment from other Universities
 DATA PRIVACY STATEMENT DATA PRIVACY CONSENT FORM
This Privacy Statement aims to inform you of the rights and
obligations under Republic Act No. 10173 or The Data I, , the
Privacy Act of 2012. undersigned have read the Data Privacy Policy of
the university and am fully aware that the
The Quezon City University (QCU) recognizes its institution is committed to protecting the privacy
responsibility in protecting personal and sensitive right of individuals on personal and sensitive
information. As a duly recognized higher educational information pursuant to the provisions of Republic
institution under the local government of Quezon City, we Act 10173 or The Data Privacy Act of 2012, its
are committed in complying with the Philippines Data implementing rules and regulations and other
Privacy Act of 2012 also known as RA 10173. This notice relevant policies, including issuances of the
shall explain the purpose and legal bases for the processing National Privacy Commission and applicable laws
of common personal and sensitive data that Quezon City and regulations relating to privacy and data
University collects and generates from data subjects. protection.
In compliance with the law, and other issuances of the
National Privacy Commission, the University declares that it In this regard, I do hereby give my consent to
will collect and generate your personal and sensitive Quezon City University to collect and process my
information starting from your application and admission personal and sensitive information which may
up to the data generated during your stay in the University. include my student number, name, contact
information, course, birth date, civil status, and
• The University will ask for the consent of the data academic performance (e.g. number of units
subject to collect and generate personal and enrolled, subject/s with grade/s obtained) and other
sensitive information to be processed by the details to pursue its legitimate interests to verify my
University Data Privacy Officer (DPO). identity, prevent fraud, process my
request/application as an educational institution.
• The data collected shall be processed in compliance
with the Republic Act No. 10173 or The Data Privacy I understand that Quezon City University is
Act of 2012 and its implementing rules and authorized to process my personal information and
regulations. sensitive personal information without the need for
my consent.
• Personal and sensitive information will be used in
the processing of applications, admission, and I further expressly agree that the concerned office
transactions within the University and other may directly obtain all my relevant student records
agencies/organizations. whether in the electronic or paper-based format in
order to verify the information.
• As the data subject, you have the right to access your
personal and sensitive data upon request and to In addition, I also confirm that the SASD and other
dispute any inaccuracies you may find. appropriate offices in the University are authorized
to provide the above information.
• The data collected will be retained in compliance
with RA 9470 also known as The National Archives I certify that the information given above is true and
of the Philippines Act of 2007 and its implementing correct.
rules and regulations. Quezon City University shall
retain the information collected and generated as Quezon City University and its offices, officers, and
necessary. employees are free from any complaint, suits, or
damages that any party may file or claim in relation
• Personal and sensitive information will be properly to Data Privacy Act.

I agree to sign this consent form.

disposed of by the University in compliance with RA

9470 also known as The National Archives of the Name and Signature of Student/Date Signed
Philippines Act of 2007 and its implementing rules
and regulations.
Conformed (Name of Parent/Guardian)/Date Signed
• You may contact us at Quezon City University by
visiting our website at https://qcu.edu.ph and our
Data Privacy Officer by email: dpo@qcu.edu.ph