Form No.

UG-11

STATEMENT OF UNDERTAKING
Please print all entries

Last Name &KXD

Given Name 6WDQOH\ /DZUHQFH

Middle Name %DOFRUWD

Academic Plan %63+< 06 Academic Year/

(Degree Code) Term

I, together with my Parent On-Record, understand and agree that, as a probationary student,
the following special terms and conditions of my enrollment apply, over and above regular
academic and student policies.

1. A Cumulative Grade Point Average (CGPA) of 1.200 or better must be earned at the end of
the first academic year or at the end of the first three (3) terms.

2. No academic or non-academic course may be dropped in the first two (2) terms.

3. A Leave of Absence (LOA) cannot be filed in the first term. Any LOA on subsequent terms
within the first academic year or the first three (3) trimesters will extend the probationary
period by the number of terms the student is on leave; and

4. Non-compliance with any of the above conditions would result to my ineligibility to re-enroll
for succeeding terms.

It is understood that after compliance with all of the above conditions, the student shall be
released from this probationary status at the end of the first academic year or the first three (3)
trimesters, unless extended. After the probationary period, regular academic and student
policies shall apply.

Student Parent On-Record

&KXD 6WDQOH\ /DZUH 0DU\ *LQ &KXD

Signature over Printed Name Signature over Printed Name

)HEUXDU\ )HEUXDU\

Date Date

**Note: This form must be accomplished in duplicate.

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