UP Visayas
OFFICE OF STUDENT AFFAIRS
Miagao, Iloilo
Application for Admission to Upper Class and Graduate Dormitories 2 x 2 photo
SY 20__- 20__
No. _______ Date received: _____________ Received by:________________
Name of Applicant: ________________________ ________________________ _________________________
Family Name Given Name Middle Name
Student No. __________ Course and Year: _____________ No. of units to be enrolled in the coming semester: ____
A. Students Information Permanent Address Mailing Address
1. Address of student
2. Contact number/s of student Landline (with area code): Mobile phone:
B. Parents information Mother: Father:
1. Name of parents
2. Address of parents
3. Occupation
4. Contact number/s of parents Landline (with area code): Mobile phone:
C. Guardians information (Note: The designated guardian shall be available within one hour upon notice. The name of the legal guardian
must be the same with the one submitted to the Health Services Unit (HSU).
1. Name of designated guardian (with conforme) while studying at UPV:
2. Address
3. Relation with the student- applicant
4. Contact number/s of guardian Landline (with area code): Mobile phone:
D. Scholarship and Financial Assistance
1. Do you have Scholarship/Sponsor for your studies at UPV aside from parents/family? ( ) Yes ( ) No
2. If yes, specify name of Scholarship/Sponsor:
3. Coverage of Scholarship/Sponsor (Please check applicable):
( ) Tuition and miscellaneous ( ) Accommodation ( ) Food ( ) Transportation ( ) Books
4. Assigned ST bracket: ( ) FDS ( ) FD ( ) PD 80 ( ) PD 60 ( ) PD 40 ( ) ND
5. Please indicate annual family income (check appropriate box)
( ) Below 80,00 ( ) 80,001-135,000 ( ) 135,001-325,000 ( ) 325,001-650,000 ( ) 650,001 1.3 M ( )1, 301,000 & above
E. References:
1. Have you stayed in any UPV dorm prior to this application? ( ) Yes ( ) No.
2. If yes, name of the Dorm ________________________________ and length of stay (no. of semesters)_________.
3. Name and contact no. of personal references: 1. __________________________________________________
2. __________________________________________________
Through this Application, I am binding myself to the following conditions:
1. Initial lodging fee equivalent to two (2) months upon check-in to cover for the first and last month of stay,
non-refundable unless refused admission to the College or upon withdrawal of application within seven (7) days
after the start of classes or payment of lodging fee (P1,500.00 per semester) and other dorm fees.
2. Payment of 50% of the remaining months in case of leaving the dormitory before the end of the semester.
3. Submit myself to a personal interview (as scheduled).
I am fully responsible for the information I voluntarily provided.
Conforme:
___________________________________________ _______________________________________________
Signature over printed name of the applicant/ Date Signature over printed name of the designated guardian/Date
Requirements are as follows:
Clearance and evaluation from the previous dorm/boarding house.
Three (3) pieces recent colored 2 x 2 picture with the name of the applicant at the back of the picture.
One (1) long, hard, cream folder with fastener
.
Only applications with complete requirements and submitted on the prescribed cut-off date shall be processed. Applicants who are dependents of UPV and
those covered with MOA which binds UPV to provide accommodation shall be given a priority slot only for the first semester or 2nd semester (as the case
may be for exchange students) but should comply with the application requirements and process (application form, interview, etc.). However, just like the
other residents eligibility for accommodation for the succeeding semesters shall be subject to the retention policy of the Dormitory.
NOTE: Dorms prohibit cooking, laundry, and ironing. Traveling to classrooms from UPV Campus dorms by tricycle costs P7.00 per person
