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1x1
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STUDENT EXCHANGE APPLICATION FORM
PERSONAL DATA
Name (Last, First, Middle):
Nationality:
Passport No.:
Date Issued:
Valid Until:
Present Address:
Gender:
Birthdate:
ST Bracket:
Permanent Address:
Contact No/s.:
E-mail Address:
Name and Signature of Parent/Legal Guardian
Contact No/s of Parent/Legal Guardian:
Student No.:
Degree Course:
Department/Institute:
College:
ACADEMIC DATA
Year Level:
UP Campus:
Year of Graduation:
Cumulative GWA:
FOREIGN UNIVERSITY APPLIED FOR
1st Choice:
2nd Choice:
3rd Choice:
Academic Year 2017-2018
MOBILITY APPLICATION FOR
[ ] 1st semester [ ] 2nd semester [ ] 1 year
CHECKLIST OF ATTACHMENTS
[ ] 1-page curriculum vitae with 1x1 photo
[ ] True Copy of Grades
[ ] Computation of General Weighted Average
certified by the Department Head or College
Secretary
[ ] Recommendation Letter from previous professor
[ ] Copy of ID
[ ] Approved Study plan (list of courses which the
student may take at a potential host university signed
by the Adviser)
[ ] 500-word essay/research plan on how the
Philippines will benefit from the student’s exchange
program
[ ] Copy of Form 5
I hereby certify upon my honor that the information provided are true and correct.
Signature over Printed Name
of Applicant
Endorsements
Date
Name and Signature of Adviser/Date
Name and Signature of Chair/Director/Date
Name and Signature of Dean/Date
Name and Signature of Vice-Chancellor for
Academic Affairs or International Relations
Officer/Date
REMINDERS:
1. Accomplish UP Student Exchange Application Form completely and submit with accompanying attachments. The
OIL/OVPAA will evaluate applications as submitted.
2. Applications must be submitted to OIL through the Vice-Chancellor for Academic Affairs or International Relations
Office only during the scheduled application periods.