POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

OPEN UNIVERSITY SYSTEM

STA. MESA, MANILA

A%ach 2” x 2” Photo
ADMISSION RECORDS
 FIRST SEMESTER  SECOND SEMESTER  SUMMER | ACADEMIC YEAR 2017-2018
REFERENCE NO.: 2018-0014-9259
PERSONAL INFORMATION
FULL NAME: ELTON JOHN CAMBA EVANGELISTA
GENDER: MALE BIRTH DATE: September 02, 1999

CIVIL STATUS: SINGLE NATIONALITY: FILIPINO

CONTACT INFORMATION
EMAIL ADDRESS: eltonjohnevangelista@yahoo.com CONTACT NO/S.: 09330823066, 9324482

ADDRESS: 20 ILANG ILANG ST. PAYATAS A QUEZON CITY QUEZON CITY, METROPOLITAN MANILA

IN CASE OF EMERGENCY
CONTACT PERSON: DAISY CAMBA CONTACT NO/S.: 9324482

ADDRESS: 20 ILANG ILANG ST. PAYATAS A QUEZON CITY, MANILA, CITY OF, METROPOLITAN MANILA, PHILIPPINES

ACADEMIC INFORMATION (LAST SCHOOL ATTENDED)

DEGREE TITLE & MAJOR: BS MECHANICAL ENGINEERING

SCHOOL NAME: EULOGIO AMANG RODRIGUEZ INSTITUTE OF SCIENCE AND TECHNOLOGY

SCHOOL ADDRESS: NAGTAHAN MANILA YEAR GRADUATED: 2013

EMPLOYMENT INFORMATION:
EMPLOYER: RALGO INDUSTRIES INC CONTACT NO/S.:
EMPLOYER ADDRESS: BRGY. CULIAT TANDANG SORA QUEZON CITY

ACADEMIC PROGRAM PREFERENCE:

PROGRAM/COURSE: MASTER OF SCIENCE IN CONSTRUCTION MANAGEMENT
- - - - - - - - - TO BE FILLED UP BY THE PROGRAM ADVISER - - - - - - - - -
SPECIALIZATION: TRACK: ✔ THESIS

EXAM RATING:
DEFICIENCY SUBJECTS (If any, must be taken within the FIRST three semesters of residency in the program):

SUBJECTS TO BE TAKEN FOR THE SEMESTER:

SUBJECT CODE SUBJECT TITLE DAY/S TIME

REMARKS:

CONFORME:

STUDENT’S SIGNATURE ADVISER’S SIGNATURE DATE

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 REPUBLIC OF THE PHILIPPINES ADMISSION STATUS:
POLYTECHNIC UNIVERSITY OF THE PHILIPPINES PRE-REGISTRATION FORM  NEW STUDENT  OLD STUDENT
OPEN UNIVERSITY SYSTEM (PLEASE WRITE LEGIBLY)  CROSS-ENROLLEE  SHIFTEE
 RETURNEE  TRANSFEREE
REFERENCE NUMBER: COMPLETE NAME: CONTACT NO.: REGISTRATION DATE:
2018-0014-9259 ELTON JOHN CAMBA EVANGELISTA
CAMPUS: ACADEMIC PROGRAM: YEAR & SECTION: CURRICULUM YEAR: ACADEMIC YEAR: SEMESTER:
2017-2018  1ST  2ND  SUMMER

SCHEDULE
SUBJECT CODE SUBJECT TITLE UNITS SECTION CODE APPROVAL
DAY TIME ROOM

INSTRUCTION: TOTAL UNITS/HOURS STUDENT’S SIGNATURE / DATE:

Fill-out this form and ensure correctness of all entries. This form is NOT VALID without
TOTAL ASSESSED FEE:
the signature of an AUTHORIZED PERSONNEL. This form serves only as your
Transac>on Form, a?er processing, immediately proceed to the ARO Office to secure ENROLLING OFFICER:
your Official Registra>on Cer>ficate.

CUT HERE

REPUBLIC OF THE PHILIPPINES ADMISSION STATUS:

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES PRE-REGISTRATION FORM  NEW STUDENT  OLD STUDENT
OPEN UNIVERSITY SYSTEM (PLEASE WRITE LEGIBLY)  CROSS-ENROLLEE  SHIFTEE
 RETURNEE  TRANSFEREE
REFERENCE NUMBER: COMPLETE NAME: CONTACT NO.: REGISTRATION DATE:
2018-0014-9259 ELTON JOHN CAMBA EVANGELISTA
CAMPUS: ACADEMIC PROGRAM: YEAR & SECTION: CURRICULUM YEAR: ACADEMIC YEAR: SEMESTER:
2017-2018  1ST  2ND  SUMMER

SCHEDULE
SUBJECT CODE SUBJECT TITLE UNITS SECTION CODE APPROVAL
DAY TIME ROOM

INSTRUCTION: TOTAL UNITS/HOURS STUDENT’S SIGNATURE / DATE:

Fill-out this form and ensure correctness of all entries. This form is NOT VALID without
TOTAL ASSESSED FEE:
the signature of an AUTHORIZED PERSONNEL. This form serves only as your
Transac>on Form, a?er processing, immediately proceed to the ARO Office to secure ENROLLING OFFICER:
your Official Registra>on Cer>ficate.
CUT HERE

Checklist: What to do next?

We have provided you with this checklist on what you are to do next. Follow through these instruc9ons to make your applica9on official
 Step 1 Medical and Dental Services (Ground Floor, North Wing Main Bldg.): Present the X-Ray film with result for the issuance of OK for
Enrollment. (For other OUS Centers: Branch/Campus Medical Office)
 Step 2 OU Registrar’s Office (4/F Ninoy Aquino Library and Learning Resources Center): For submission of entrance requirements
including the OK for Enrollment and ALL ORIGINAL documents and tagging of subjects. (For other OUS Centers: Branch/Campus Registrar)
 Step 3 Program Chairperson (4/F Ninoy Aquino Library and Learning Resources Center): For advising of subjects to be enrolled.
(For other OUS Centers: Branch/Campus Academic Head)
 Step 4 Fund Management Office (Ground Floor, South Wing Main Building): For payment of fees. (For other OUS Centers:
Branch/Campus Cashier Office)
Note: Registra9on Cer9ficate will be issued on the first day of offline session at the OUS (or Branch/Campus) Registrar Office.

Checklist: What to bring

 Original Transcript of Records (TOR) from  Two copies ID picture, 2"x2" (recent and  Original NSO Birth Cer9ficate
school last a%ended. iden9cal, formal aFre w/ white
background)
 Service Record or Cer9ficate of  Le%er of Recommenda9on from  One (1) long brown envelope.
Employment. Immediate Supervisor
 Original NSO Marriage Cer9ficate for female  Latest X-Ray result with film (taken within
married students the last two months)
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 ENROLLMENT SCHEDULE FOR THE GRADUATE PROGRAM
SUMMER 2018

PB W/ STUDENT INFORMATION SYSTEM (SIS)

OUS-MANILA
COURSES OFFERED:  MASTER IN COMMUNICATION
 MASTER IN EDUCATIONAL MANAGEMENT
DATE OF ENROLMENT: NEW STUDENTS:
APRIL 10 TO 25, 2018
 MASTER IN PUBLIC ADMINISTRATION
 MASTER OF SCIENCE IN CONSTRUCTION MANAGEMENT
DATE OF ENROLMENT: NEW STUDENTS:
APRIL 10 TO 18, 2018
ISSUANCE OF AFTER PAYMENT TO CASHIER, PLEASE PRESENT YOUR RECEIPT AT THE OUS STUDENT
REGISTRATION CARD SERVICES

SCHEDULE OF INTERVIEW FOR MSIT NEW STUDENTS, PLEASE GO TO OUS LEARNING MANAGEMENT SYSTEM
(OFFICE OF INSTITUTE OF OPEN AND DISTANCE EDUCATION) 4TH FLOOR NALLRC BLDG. PUP MABINI
CAMPUS, STA. MESA, MANILA
COURSES OFFERED:  MASTER IN INFORMATION TECHNOLOGY
DATE OF ENROLMENT: SCHEDULE OF SCREENING: APRIL 10 TO 18 (9:00 A.M. – 5:00 P.M.)

OUS-QUEZON CITY
COURSES OFFERED:  MASTER IN EDUCATIONAL MANAGEMENT
 MASTER IN PUBLIC ADMINISTRATION
DATE OF ENROLMENT: NEW/OLD STUDENTS:
APRIL 10 TO 25, 2018

OUS-STO. TOMAS, BATANGAS & UNISAN, QUEZON

COURSES OFFERED:  MASTER IN EDUCATIONAL MANAGEMENT
 MASTER IN PUBLIC ADMINISTRATION
DATE OF ENROLMENT: NEW/OLD STUDENTS:
APRIL 10 TO 25, 2018

OUS-LOPEZ, QUEZON
COURSES OFFERED:  MASTER IN EDUCATIONAL MANAGEMENT
 MASTER IN PUBLIC ADMINISTRATION
 MASTER OF SCIENCE IN CONSTRUCTION MANAGEMENT
DATE OF ENROLMENT: NEW/OLD STUDENTS:
APRIL 10 TO 25, 2018

OUS-TAGUIG
COURSES OFFERED:  MASTER IN EDUCATIONAL MANAGEMENT
DATE OF ENROLMENT: NEW/OLD STUDENTS:
APRIL 10 TO 25, 2018

OUS- MARAGONDON, CAVITE

COURSES OFFERED:  MASTER IN EDUCATIONAL MANAGEMENT
DATE OF ENROLMENT: NEW/OLD STUDENTS:
APRIL 10 TO 25, 2018

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 UNDERTAKING
I, _________________________________________, with student number _________________,
hereby acknowledge that I have not submitted the following documents to the Open University
System.

 TRANSCRIPT OF RECORDS WITH REMARKS “COPY FOR PUP OPEN UNIVERSITY SYSTEM”
 ORIGINAL COPY OF PSA/NSO BIRTH CERTIFICATE
 ORIGINAL COPY OF PSA/NSO MARRIAGE CERTIFICATE (for female married applicant)
 CERTIFICATE OF EMPLOYMENT/SERVICE RECORD
 LETTER OF RECOMMENDATION FOR IMMEDIATE SUPERVISOR

I hereby undertake to submit the aforesaid requirements on or before _____ Semester, A.Y.
20___-20___. Should I fail to submit said requirements on afore-stated period, the subjects that
I have taken in the Open University System shall be considered waived, and invalidated and
without any effect whatsoever. Thus, the same should not be considered and/or credited in my
favour.

I also declare under oath that I am not currently enrolled in any Post/Graduate Program, and
will not do so without formally notifying in writing the Registrar’s Office of the PUP Open
University System.

Further, I hereby affirm that all information given herewith are complete and accurate. I am
aware that any or all of the information furnished in this application may be checked against
original documents and that concealing/or giving false information will disqualify me for
admission and/or subject me for dismissal.

Furthermore, I agree to finish the program within the prescribed period otherwise this will be a
ground for my honorable dismissal. I agree to abide by the policies, rules and regulations of the
Polytechnic University of the Philippines – Open University System.

________________________________________
SIGNATURE OVER PRINTED NAME

SUBSCRIBED AND SWORN to before me this _____ day of ________, 20____, by affiant exhibited to me
his/her Community Tax Certificate No. _______________________________. Issued on
___________________________ at ________________.

Doc No. ;
Page No. ;
Book No. ;
Series of 20__. ;

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 Republic of the Philippines
Polytechnic University of the Philippines
Office of the Vice President for Academic Affairs
Open University System

______________________
DATE

THE REGISTRAR
________________________________
(NAME OF LAST SCHOOL ATTENDED)

________________________________
(ADDRESS)

Dear Sir/Madam:

I have the honor to request for the original copy of Transcript of Records/Form 137-A of
MR/MS. _______________________________________ who has been
admitted in this University upon presenting his/her entrance credentials.

Please indicate in the remarks “Copy for PUP Open University System” and
entrust the same to the bearer in a Sealed Envelope.

Your early attention on this matter will be highly appreciated. Thank you.

Very truly yours,

ELIZABETH C. FERNANDO, MEM

Registrar

 1st Request
 2nd Request
 3rd Request
 Urgent
 Please hand-carry in a sealed envelope

4/F NALLRC Bldg. PUP A. Mabini Campus, Anonas Street, Sta. Mesa, Manila
Phone: (Direct Line) 3100409; (Trunk Line) 7167832 local 325; Website: www.pup.edu.ph/ous
Email: ousregistrar@pup.edu.ph

THE COUNTRY’S 1st POLYTECHNICU

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