6/20/2019 PIT | Application Form

Republic of the Philippines

PALOMPON INSTITUTE OF TECHNOLOGY
Palompon, Leyte

GUIDANCE CENTER
Tel. No. (053) 555 - 8458

Examinee No. : 20181561015781846

APPLICATION FORM
COLLEGE ENTRANCE EXAMINATION 2x2 colored ID Picture with
SY __2019-2020__ nametag
(Lastname, Firstname,
Middlename)

ACADEMIC STATUS OF APPLICANT

   Currently enrolled as Grade 12 Student

   A Senior High School Graduate
   A High School Graduate of the old curriculum (BEC)
   Alternative Learning System (ALS) Passer
   Phillippine Educational Placement Test (PEPT) Passer
   Second (2nd) Courser
   Transferee
   Returnee
   Others

BACKGROUND INFORMATION

Last Name WENCESLAO

First Name ROLDEN

Middle Name ABING

Sex:   Male   Female     Nationality:   __FILIPINO__

Contact Information
Permanent Home Address: BARANGAY DISTRICT 26 ISLA VERDE ORMOC CITY LEYTE Zip Code: 6541
House No., Street, Barangay City/Municipality Province
Telephone/Cell phone No.: 09075566865 Email Address (if available): WWW.W.ROLDEN@YAHOO.COM

SCHOOL ATTENDED (Where you last attended/are currently completing secondary level education)
Name of School: ST. ALOYSIUS INSTITUTE OF TECHNOLOGY

Complete Address: ORMOC ST, ORMOC CITY, LEYTE

Degree/Course Attained (for transferee/second courser): N/A

Senior High School Track (for SHS graduate): TVL

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6/20/2019 PIT | Application Form

PROGRAM APPLYING FOR

Bachelor of Technical-Vocational Teacher Education - Bachelor of Technology and Livelihood Education -

1st Choice: 2nd Choice:
Garments, Fashion and Design Home Economics

For Freshmen (SHS, ALS, PEPT, BEC graduate) Grade Requirements

Certi ed true copy of HS or SHS Form 138 in Grade 11 and Grade 12
Maritime Courses Grade Requirement for Freshmen:
Duly authenticated copy of the PEPT/ALS A&E Test Certi cate of Rating
80% GWA/GPA
3 pcs. recent 2x2 ID picture (colored background, with name tag and
80% average grade for English
wearing a decent attire).
80% average grade for Math
Properly lled-out application form.
80% average grade for Science
Transferees and Second Coursers (College)
Maritime Courses Grade Requirement for Transferees/Second
Certi ed true copy of Transcript of Records / Report of Rating
Report of Rating duly signed by an authorized o cial (for currently Courser:
enrolled applicants) GWA of 2.5
Certi cation of Enrollment (for currently enrolled applicants)
3 pcs. recent 2x2 ID picture (colored background, with name tag and Education Courses Grade Requirement:
wearing a decent attire). 85% GWA/GPA for Freshmen
Properly lled-out application form. GWA of 2.0 for Transferees/Second Courser

Other Courses Grade Requirement

80% GWA/GPA for Freshmen
GWA of 2.5 for Transferees/Second Courser

Data Privacy Consent

The Palompon Institute of Technology is collecting personal information for the purpose of:

Facilitating admission to the Institute

Determining eligibility for the program applied
Transmittal of data internally to other o ces/unit entities for any legitimate purpose
Data sharing to other government agencies who has mandates for processing student personal data (ex. Commission on Higher Education, TESDA, etc.)
Other legitimate requests for data processing which the student will be noti ed and asked for separate consent

I hereby certify that all information supplied in this application form are true, complete and accurate. I understand that any false or
incomplete entry may cause my disquali cation for admission.

I have read and understood the Institute's Data Privacy Statement and express my consent for the Palompon Institute of Technology to
collect, record, organize, update or modify, retrieve, use, consolidate, block, erase or destroy my personal data.

I hereby a rm my right to be informed, object to processing, access and rectify, suspend or withdraw my personal data, and be
indemni ed in case of damages pursuant to the provisions of the Republic Act No. 10173 of the Philippines or Data Privacy Act of 2012 and its
corresponding Implementing Rules and Regulations.

__________________________________________ ____________________
Signature over Printed Name Date

PIT Vision:
A Premier Polytechnic State University

PIT Mission:
To strengthens its capacity of producing higly skilled, competent, and world-class human resources, responsible to ful ll stakeholder needs, goals of the
national development and ASEAN integration, for the attainment of a good quality of life with the guidance and providence of God.

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6/20/2019 PIT | Application Form

Republic of the Philippines

PALOMPON INSTITUTE OF TECHNOLOGY
Palompon, Leyte

GUIDANCE CENTER
Tel. No. (053) 555 - 8458

Examination Permit

Name of Examinee: Examinee No.: 20181561015781846

WENCESLAO, ROLDEN ABING

Testing Venue: Function Hall, 2nd Flr, Student Service Center
Building

Time of Exam: 03:00 pm - 05:00 pm

2x2 colored ID Picture with
Date of Exam: June 24, 2019
nametag
(Lastname, Firstname,
Examinee Signature: _______________________ Middlename)

NOTE:
1. Present this exam permit to the examiner before taking the exam.
2. Please be at the testing site 30 min. before the exam starts.
3. Examinees without exam permits are not allowed to take the test.
4. Late examinees are not allowed to take the test.
5. Please bring black ballpen and pencil (preferably no. 2).
6. Bring your snacks ( if desired). No one is allowed to leave the room until CHERRIE RED L. ABILAR
testing is over.
OIC - Guidance Coordinator

Republic of the Philippines

PALOMPON INSTITUTE OF TECHNOLOGY
Palompon, Leyte

GUIDANCE CENTER
Tel. No. (053) 555 - 8458

Examination Permit

Name of Examinee: Examinee No.: 20181561015781846

WENCESLAO, ROLDEN ABING

Testing Venue: Function Hall, 2nd Flr, Student Service Center
Building

Time of Exam: 03:00 pm - 05:00 pm

2x2 colored ID Picture with
Date of Exam: June 24, 2019
nametag
(Lastname, Firstname,
Examinee Signature: _______________________ Middlename)

NOTE:
1. Present this exam permit to the examiner before taking the exam.
2. Please be at the testing site 30 min. before the exam starts.
3. Examinees without exam permits are not allowed to take the test.
4. Late examinees are not allowed to take the test.
5. Please bring black ballpen and pencil (preferably no. 2).
6. Bring your snacks ( if desired). No one is allowed to leave the room until CHERRIE RED L. ABILAR
testing is over.
OIC - Guidance Coordinator

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