GUIDELINES IN ACCOMPLISHING THE PLV CAT 2023 APPLICATION FORM

1. FILL OUT THE PLV CAT 2023 APPLICATION FORM USING MS EXCEL APPLICATION
(HANDWRITTEN APPLICATION FORM WILL NOT BE ACCEPTED)

2. PRINT THE PLV CAT 2023 APPLICATION FORM IN A 8.5 X 13" (LONG) BOND PAPER.
PRINT THE FORM IN A BACK TO BACK SET UP.
(FORMS PRINTED IN 8.5 X 11" (SHORT) BOND PAPER WILL NOT BE ACCEPTED)

3. ATTACH ONE (1) PASSPORT SIZE ID PICTURE ON THE DESIGNATED AREA

4. CHECK THE COMPLETENESS AND CORRECTNESS OF THE INFORMATION/DATA ON THE

PLV CAT 2023 APPLICATION FORM

5. TYPE YOUR NAME AND SIGN THE APPLICATION FORM AND INDICATED THE PREPARATION
DATE WHEN YOU HAVE ACCOMPLISHED THE FORM

6. ARRANGE THE APPLICATION FORM AND THE REQUIRED DOCUMENTARY REQUIREMENTS

IN ORDER BASED ON THE APPLICATION POSTING
 PAMANTASAN NG LUNGSOD NG VALENZUELA PLV CAT APPLICATION NO.
COLLEGE ADMISSION TEST
SCHOOL YEAR 2023-2024

INSTRUCTIONS: READ THE APPLICATION QUALIFICATIONS. DO NOT APPLY IF NOT QUALIFIED. Fill in all the required information. DO NOT leave an item blank. If an item is
not applicable, indicate “N/A”. Only fully accomplished form will be accepted. Credentials filed in support of this application will become the property ofthis institution and will not be
returned to the applicant.

A. NAME OF APPLICANT (AS IT APPEARS ON THE BIRTH CERTIFICATE)

1 LAST NAME De Vera
Raizelle
FIRST NAME NAME EXTENSION N/A
MIDDLE NAME Romero
B. FACTS OF BIRTH
2 DATE OF BIRTH (MM/DD/YYY) 3 PLACE OF BIRTH (CITY/MUN./PROVINCE) 4 GENDER 5 CITIZENSHIP 6 AGE

Valenzuela City FEMALE Filipino 17

7 BLOOD TYPE 8 CIVIL STATUS 9 RELIGION 10 BIRTH ORDER 11 NO. OF SIBLINGS

A+ SINGLE Catholic 1 1
C. ADDRESS & CONTACT DETAILS
12 CURRENT ADDRESS HOUSE/ROOM/FLOOR/BLOCK /LOT/PHASE/STREET/SUBD. BARANGAY CITY/MUNICIPALITY DISTRICT ZIP CODE

233 Matiaga Street Area 2 Pinalagad MALINTA Valenzuela City I 1440

13 PERMANENT ADDRES HOUSE/ROOM/FLOOR/BLOCK /LOT/PHASE/STREET/SUBD. BARANGAY CITY/MUNICIPALITY DISTRICT ZIP CODE

233 Matiaga Street Area 2 Pinalagad MALINTA Valenzuela City I 1440

14 ACTIVE EMAIL ADDRESS 15 SOCIAL MEDIA (FACEBOOK URL ADDRESS/ID) 16 ACTIVE MOBILE NUMBER 17 TELEPHONE NUMBER
raizelledevera25@gmail.com https://www.facebook.com/raizelle.devera25?mibextid=ZbWKwL 9668741555 N/A
D. FAMILY DATA
FIRST NAME MIDDLE NAME LAST NAME NAME EXTENSION PHYSICAL EXISTENCE
18 FATHER'S INFORMATION
Ryann Tan De Vera N/A ALIVE
AGE HIGHEST EDUCATIONAL ATTAINMENT CURRENT OCCUPATION AVERAGE INCOME PER MONTH MOBILE NUMBER TELEPHONE NUMBER

41 College (Undergraduate) Tricycle Driver 9195946385

FIRST NAME MAIDEN MIDDLE NAME MAIDEN LAST NAME NAME EXTENSION PHYSICAL EXISTENCE
19 MOTHER'S INFORMATION
Maricel Gabrillo Romero N/A ALIVE
AGE HIGHEST EDUCATIONAL ATTAINMENT CURRENT OCCUPATION AVERAGE INCOME PER MONTH MOBILE NUMBER TELEPHONE NUMBER

35 College ( Undergraduate) Strore Manager 18,000

20 MARITAL STATUS OF PARENTS 21 APPLICANT'S LIVING STATUS 22 HOME OWNERSHIP STATUS 23 TOTAL NO. OF HOUSEHOLD MEMBER

MARRIED LIVING WITH BOTH PARENTS INHERITED 9

24 TOTAL NO. OF HOUSEHOLD MEMBER WITH WORK 25 GROSS MONTHLY FAMILY INCOME 26 TOTAL MONTHLY EXPENSES

3 15001-20000 5001-10000
27 GUARDIAN'S DETAIL FIRST NAME MIDDLE NAME LAST NAME NAME EXT. RELATIONSHIP MOBILE NUMBER

E. EDUCATIONAL BACKGROUND
28 ARE YOU CURRENTLY ENROLLED? YES 29 Senior High School Program (GRADE 12)
IF "YES" WHAT PROGRAM IS IT?

30 NAME OF SCHOOL LAST ATTENDED (DO NOT ABBREVIATE) Malinta National High School - Senior High School
31 SCHOOL'S MAILING ADDRESS (NOT THE EMAIL ADDRESS) 305438
32 Academic Track - Humanities and Social Sciences Strand
TRACK/STRAND/PROGRAM/COURSE/MAJOR LAST TAKEN (OR YOU ARE CURRENTLY ENROLLED)
33 LEARNER REFERENCE NO. 34 ESC NO. (IF APPLICABLE) 35 DATE OF GRADUATION 36 NO. OF SEMESTER COMPLETED (IF APPLICABLE)

227001100083 N/A July 2023 1

37 ENROLLMENT HISTORY NAME OF SCHOOL SCHOOL'S MAILING ADDRESS PERIOD OF ATTENDACE (FROM - TO)
COLLEGE/VOCATIONAL N/A N/A N/A

GRADE 12 Malinta National High School

GRADE 11 Malinta National High School

GRADE 10 Malinta National High School

GRADE 9 Malinta National High School

GRADE 8 Malinta National High School

GRADE 7 Malinta National High School

F. INTENDED COURSE OF STUDY (UNDERGRADUATE PROGRAM)

FIRST CHOICE (COURSE/MAJOR)
38 Bachelor of Science in Psychology (BSP)

SECOND CHOICE (COURSE/MAJOR)

39 Bachelor of Science in Social Work (BSSW)

WHY DO YOU CHOOSE THE FOLLOWING COURSE?

While my second choice, BS Social Work, is also my interest and is more inclined to my dream profession that would help me gain prior knowledge and skill for my chosen career in the future.

RAIZELLE R. DE VERA

Printed Name of Applicant Signature of the Applicant Date

 PAMANTASAN NG LUNGSOD NG VALENZUELA
COLLEGE ADMISSION TEST
SCHOOL YEAR 2023-2024

G. ORGANIZATIONAL AFFILIATION
40A NAME OF ORGANIZATION 40B NAME OF ORGANIZATION

TYPE OF ORGANIZATION TYPE OF ORGANIZATION

POSITION ON THE ORGANIZATION POSITION ON THE ORGANIZATION

40C NAME OF ORGANIZATION 40D NAME OF ORGANIZATION

TYPE OF ORGANIZATION TYPE OF ORGANIZATION

POSITION ON THE ORGANIZATION POSITION ON THE ORGANIZATION

H. OTHER INFORMATION
ARE YOU A PERSON WITH DISABILITY?

41 IF "YES", PLEASE SPECIFY THE TYPE OF DISABILITY

PLEASE PROVIDE THE PWD ID NO.

DO YOU HAVE ILLNESS / MEDICAL CONDITION?

42 IF "YES", PLEASE SPECIFY THE DETAILS OF ILLNESS

MEDICAL CONDITION

ARE A MEMBER OF ANY INDIGENOUS GROUP?

43
IF "YES", PLEASE SPECIFY THE DETAILS

44 IS YOUR FAMILY A HOUSEHOLD BENEFICIARY OF 4PS?

45 ARE YOU RELATED BY CONSANGUINITY/AFFINITY TO ANY PLV EMPLOYEE? IF "YES", PLEASE SPECIFY THE DETAILS

45A NAME OF THE PLV EMPLOYEE 45B NAME OF THE PLV EMPLOYEE

DEPARTMENT OF THE EMPLOYEE DEPARTMENT OF THE EMPLOYEE

RELATIONSHIP TO THE EMPLOYEE RELATIONSHIP TO THE EMPLOYEE

45C NAME OF THE PLV EMPLOYEE 45D NAME OF THE PLV EMPLOYEE

DEPARTMENT OF THE EMPLOYEE DEPARTMENT OF THE EMPLOYEE

RELATIONSHIP TO THE EMPLOYEE RELATIONSHIP TO THE EMPLOYEE

46 ARE YOU RELATED BY CONSANGUINITY/AFFINITY TO ANY VALENZUELA CITY GOVERNMENT EMPLOYEE? IF "YES", PLEASE SPECIFY THE DETAILS

46A NAME OF THE VCG EMPLOYEE 46B NAME OF THE VCG EMPLOYEE

DEPARTMENT OF THE EMPLOYEE DEPARTMENT OF THE EMPLOYEE

RELATIONSHIP TO THE EMPLOYEE RELATIONSHIP TO THE EMPLOYEE

46C NAME OF THE VCG EMPLOYEE 46D NAME OF THE VCG EMPLOYEE

DEPARTMENT OF THE EMPLOYEE DEPARTMENT OF THE EMPLOYEE

RELATIONSHIP TO THE EMPLOYEE RELATIONSHIP TO THE EMPLOYEE

47
DO YOU HAVE ANY FAMILY MEMBER/S WITHIN THE 3RD DEGREE OF CONSANGUINITY WHO GRADUATED/STUDIED/OR CURRENTLY ENROLLED AT PLV?
IF "YES, PLEASE SPECIFY THE DETAILS

47A NAME OF THE STUDENT 47B NAME OF THE STUDENT

COURSE & MAJOR COURSE & MAJOR

YEAR GRADUATED / ATTENDANCE YEAR GRADUATED / ATTENDANCE

RELATIONSHIP TO THE STUDENT RELATIONSHIP TO THE STUDENT

47C NAME OF THE STUDENT 47D NAME OF THE STUDENT

COURSE & MAJOR COURSE & MAJOR

YEAR GRADUATED / ATTENDANCE YEAR GRADUATED / ATTENDANCE

RELATIONSHIP TO THE STUDENT RELATIONSHIP TO THE STUDENT

I. DECLARATION

I declare under oath that I personally accomplished this application form, and I hereby certify that all the information
given are true, correct, and complete statements. Further, I understand that the acceptance and approval of my
application for admission is based on the aforestated information.

I therefore agree that, in case of post-verification yields information contrary to what is declared, my application shall
be disapproved and I will be disqualified to apply.

Further, I hereby give my consent to the Pamantasan ng Lungsod ng Valenzuela that the abovementioned data may
form part of its database that can be used for relevant purposes but may not be limited to profiling and research, and
especially as a basis of data-driven decisions of the University.

Printed Name of Applicant Signature of the Applicant Date