____________________________________________________________________________________________

UNIVERSITY OF THE PHILIPPINES

COLLEGE OF MASS COMMUNICATION

AUTHORIZATION FORM

(ACCESS TO AND/OR RELEASE OF STUDENT'S CURRICULUM CHECKLIST

FOR ENROLLMENT AND/OR REGISTRATION PURPOSES)

INSTRUCTIONS

Pursuant to laws and rules governing data privacy in the Philippines, the University of the Philippines College of Mass
Communication (UPCMC) will not allow access to or release of the curriculum checklist and its corresponding entries and attachments
thereto, by or to college and university registration personnel, including program advisers, department administrators and registration
assistants, unless the release thereof is duly authorized by the student concerned, embodied in this authorization form. The signature
of the student (and that of the student's parent or guardian in case the student is a minor) shall constitute express permission from
the student for the grant of access to or release of the student's curriculum checklist and its corresponding entries and attachments
as above-stated. It is understood that the use of the same shall be limited to enrollment and registration purposes only, and shall not
be accessible by unauthorized individuals. The student shall indicate his or her full name and the pertinent dates, and affix his or her
signature in the appropriate spaces indicated herein below. In case the student is a minor (below 18 years of age) as of this date, the
parent or guardian shall likewise indicate his or her name and affix his or her signature in the appropriate spaces below. Please make
sure that names are legible. Students and their representatives who indicate false information or falsified entries on this form shall be
held legally liable for the same.

ACCOMPLISH BELOW

I, a current bona fide student of the University of the Philippines College of Mass Communication (UPCMC), do hereby
authorize the UPCMC to allow access to or to release my official curriculum checklist (including the entries therein and the attachments
thereto) to appropriate college and university enrollment and registration personnel, including program advisers, department
administrators and registration assistants, for the purpose of processing my enrollment and/or registration in subjects and courses
offered by the UPCMC or other units in the University of the Philippines System. This form shall be valid only for the enrollment or
registration period it is to be used, and shall be kept in my curriculum checklist record on file with the UPCMC.

Josemari Luis Cunanan Lagman

FULL NAME OF STUDENT SIGNATURE OF STUDENT
(PLEASE INDICATE ABOVE) (PLEASE SIGN ABOVE)

202210365 BA Broadcast Media Arts and Studies

STUDENT NUMBER DEGREE PROGRAM
(PLEASE INDICATE ABOVE) (PLEASE INDICATE ABOVE)

Cecile Angela A. Ilagan Assoc. Prof. Alwin C. Aguirre, PhD

FULL NAME OF PROGRAM ADVISER FULL NAME OF DEPARTMENT CHAIRPERSON
(PLEASE INDICATE ABOVE) (PLEASE INDICATE ABOVE)

May 2, 2023 September 8, 2004

DATE TODAY BIRTHDATE OF STUDENT
(PLEASE INDICATE ABOVE) (PLEASE INDICATE ABOVE)

The section below shall be accomplished by students who are minors (below 18 years old) on the date this form is accomplished.

FULL NAME OF PARENT OR GUARDIAN SIGNATURE OF PARENT OR GUARDIAN

(PLEASE INDICATE ABOVE) (PLEASE SIGN ABOVE)