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

, AY2022-2023)

QUEZON CITY UNIVERSITY

673 Quirino Hi-way, San Bartolome, Novaliches Q.C.
2x2
ADMISSIONS OFFICE ID Picture
White Background
STUDENT APPLICATION FORM
___SEM, AY:____
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.
Date of Application: LRN:136537120383 Student No.: (to be filled out by the admission officer)

Are you applying as (Please check the appropriate answer)

SHS Graduating this July Track: Strand:
SHS Graduate Track: Strand:
High School Graduate (Year 2015 and below Graduated in HS) ALS Graduate
Transferee, Are you applying for Accreditation of Subjects? Ye No
s
2nd Degree Course Taker (already a graduate of a Bachelor’s Degree before) Course:
Course applied for: Please choose 3 preferred courses. Rank (1) 1 st Choice (2) 2nd Choice (3) 3rd Choice
2 Bachelor of Science in Management Accounting (BSMA) 1 Bachelor of Science in Accountancy (BSA)
3 Bachelor of Science in Entrepreneurship (BS ENTREP) Bachelor of Early Childhood Education (BECEd)
Bachelor of Science in Industrial Engineering (BSIE) Bachelor of Science in Electronics Engineering (BSECE)
Bachelor of Science in Computer Science (BSCS) Bachelor of Science in Information System (BSIS)
Bachelor of Science in Information Technology (BSIT)
Please Rank preferred Campus: Rank (1) 1st Choice (2) 2nd Choice (3) 3rd Choice
3 Batasan Campus 2 San Bartolome Campus 1 San Francisco Campus
Are you presently enrolled? If yes, Name of School Date of Last Day of
Classes
PERSONAL INFORMATION (As indicated in your PSA Birth Certificate. Use your husband’s surname if married)
Last Name: DIAZ First Name: ALICIA MAE Middle Name: PAYOT

Gmail Address: Date of Birth: 05/17/2004 Gender: Religion: Citizenship: FILIPINO

[email protected] FEMALE CATHOLIC
Contact Number: 09458202186 Place of Birth: QUEZON CITY Civil Status: If Married, Name of Spouse:
SINGLE
Present Address:
7 OAK EXTENSION
Barangay: FAIRVIEW City/ Municipality: QUEZON CITY District No. Zip Code 1118
Do you have a physical/behavioral condition/Disability? Specify

EDUCATIONAL BACKGROUND
College: (Leave it blank if never enrolled in college) LA CONCEPCION COLLEGE

Address: KAYPIAN ROAD, QUIRINO HIGHWAY CITY OF SAN JOSE DEL MONTE BULACAN

Location: QC ✓ Non-QC Public ✓ Private School

School
Course: BACHELOR OF SCIENCE IN Date Graduated: Honors Received with certification:
ACCOUNTANCY (1ST SEM ONLY)
 Technical Vocational: (Leave it blank if never enrolled in technical vocational courses)

Address:
Location: QC Non- Public School Private School
QC
Course/Year/s Taken: Date Graduated: Honors Received with certification:

Senior High School Name or High School Name for HS Graduate: SAN MARTIN NATIONAL HIGH SCHOOL

Address: ILANG ILANG ST. PUROK 6, SAN MARTIN III, AREA C

Location: QC ✓ Non- ✓ Public School Private School
QC
Track/Strand: ABM Section: 12-ZUCKERBERG Date Honors Received with certification:
Graduated: JULY WITH HONOR
13, 2023

AO Form 1- Revised 2022 (Effective 1st Sem., AY2022-2023)

FAMILY BACKGROUND
Father’s Name: RONNIE B. DIAZ Occupation: CONSTRUCTION Educ’l Contact No.: 09212157047
SR. WORKER Attainment:
HIGH SCHOOL
GRADUATE
Mother’s Name: ALY P. DIAZ Occupation: HOUSE WIFE Educ’l Contact No.: 09671672174
Attainment:
ELEMENTARY
GRADUATE
Parent’s Address: 7 OAK EXTENSION, FAIRVIEW QUEZON CITY

Guardian: ALY P. DIAZ Relationship: MOTHER Contact No.: 09671672174

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

Name: JOANNA MARIE P. DIAZ Relationship: SISTER
Name: Relationship:
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
Name: ALY P. DIAZ Relationship: MOTHER Contact No.: 09671672174

Address: 7 OAK EXTENSION, FAIRVIEW 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
picture white background with name tag and student’s signature at the Fully Accomplished QCU Admission Application Form with 2x2
back on the space below the form. (2sets) colored picture white background with name tag and student’s
signature at the back on the space below the form. (2sets)
2. Original SF9 (Certified True Copy of Grade 11 & Original Grade 12) 2. Transcript of Records (For Evaluation Purposes)
Form 138- High School Report Card
Alternative Learning System Certificate of Rating if ALS passer

3. Original PSA Birth Certificate 3. Original PSA Birth Certificate

4. Original Certificate of Good Moral Character 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) 7. Original Certificate of Transfer Credentials (CTC)

8. Medical Clearance – Issued by the Medical and Dental Services 8. Medical Clearance – Issued by the Medical and Dental Services

Additional Requirements for the following Applicants: Additional Requirements for the following Applicants:
⮚ If with discrepancy between PSA Birth Certificate and School Record – ⮚ For Accreditation of Subjects during enrollment period –
Affidavit of the Same Person Subject Course Description of all passed subjects, TOR Copy
for QCU and NSTP 2 Serial Number (Secure request letter
⮚ If currently employed - Original Latest Certificate of Employment from QCU Admissions Office)
⮚ If Married Female Student - Original Marriage Certificate ⮚ If with discrepancy between PSA Birth Certificate and School
Record – Affidavit of the Same Person
⮚ Applicants from schools with non-numerical (Pass/Fail) grades-
⮚ If currently employed - Original Latest Certificate of
Certificate of Non-issuance of Numerical Grades (Issued by the School
Registrar) Employment

⮚ In cases where the student-applicant cannot reasonably secure his/her

⮚ If Married Female Student - Original Marriage Certificate

school credentials for reasons beyond his/her control, such as: Closure ⮚ Applicants from schools with non-numerical (Pass/Fail)
of the school last attended and Damage of documents due to fire or grades-Certificate of Non-issuance of Numerical Grades
natural calamities - Certificate of eligibility for admission to college from (Issued by the School Registrar)
the Commission on Higher Education (CHED)
⮚ In cases where the student-applicant cannot reasonably
⮚ Applicants who stopped for 1 Yr or more - Affidavit of Non-Enrollment secure his/her school credentials for reasons beyond his/her
from other Universities 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 I, ______________________________________________________,
obligations under Republic Act No. 10173 or The Data Privacy Act of
2012.
the undersigned have read the Data Privacy Policy
of the university and am fully aware that the
The Quezon City University (QCU) recognizes its responsibility in institution is committed to protecting the privacy
protecting personal and sensitive information. As a duly recognized
higher educational institution under the local government of Quezon right of individuals on personal and sensitive
City, we are committed in complying with the Philippines Data Privacy information pursuant to the provisions of Republic
Act of 2012 also known as RA 10173. This notice shall explain the Act 10173 or The Data Privacy Act of 2012, its
purpose and legal bases for the processing of common personal and
sensitive data that Quezon City University collects and generates from implementing rules and regulations and other
data subjects. relevant policies, including issuances of the
The University ensures that only individuals that met the
National Privacy Commission and applicable laws
requirements shall be accepted. In compliance with the law and other and regulations relating to privacy and data
issuances of the National Privacy Commission, the University declares protection.
that it will collect and generate your personal and sensitive
information starting from your application and admission up to the
data generated during your stay in the University. In this regard, I do hereby give my consent to
● The University will ask for the consent of the data Quezon City University to collect and process my
subject to collect and generate personal and sensitive personal and sensitive information to pursue its
information to be processed by the University Data legitimate interests as an educational institution.
Privacy Officer (DPO).
● The data collected shall be processed in compliance with
Quezon City University and its offices, officers, and
the Republic Act No. 10173 or The Data Privacy Act of
employees are free from any complaint, suits, or
2012 and its implementing rules and regulations.
damages that any party may file or claim in relation
● Personal and sensitive information will be used in to Data Privacy Act.
processing applications, admission, and transaction with
the University. I agree to sign this consent form.
● As the data subject, you have the right to access your
personal and sensitive data upon request and to dispute ___________________________________________________
any inaccuracies you may find. Name and Signature of Student/Date Signed

● The data collected will be retained in compliance with

RA 9470 also known as The National Archives of the
Philippines Act of 2007 and its implementing rules and ___________________________________________________________
regulations. Quezon City University shall retain the _
information collected and generated as necessary. Conforme (Name of Parent/Guardian)/Date Signed

● Personal and sensitive information will be properly

disposed of by the University in compliance with RA
9470 also known as The National Archives of the
Philippines Act of 2007 and its implementing rules and
regulations.

● You may contact us at Quezon City University by visiting

our website at https://qcu.edu.ph and our Data Privacy
Officer by email: [email protected]