SCHOLARSHIP PROGRAM
APPLICATION FORM Photo
(2021 Revised Edition)
I PERSONAL DATA
NAME
(Family Name) (First Name) (Middle Name)
COMPLETE POSTAL ADDRESS
DATE OF BIRTH Place of Birth
AGE Sex Civil Status Religion
PERMANENT CONTACT NUMBER
NAME ON FACEBOOK
EMAIL ADDRESS
II EDUCATIONAL DATA
LEVEL NAME & ADDRESS OF SCHOOL YEAR HONORS/AWARDS
GRADUATED RECEIVED
Elementar
y
Secondar
y
Senior
High
WEIGHTED AVERAGE
- Incoming 1st Year (Average Grade 12 Grade)
- College Student (Previous Sem Average Grade)
COURSE YOU INTEND TO ENROLL YR/LEVEL
NAME & ADDRESS OF SCHOOL
DO YOU HAVE ANY SCHOLARSHIP APPLICATION? IF YES, PLEASE STATE SCHOLARSHIP GRANTOR.
ARE YOU A WORKING STUDENT? IF YES, HOW MUCH DO YOU RECEIVE?
WHAT IS THE BIGGEST SOURCE OF INCOME OF THE HOUSEHOLD? `
Business Dividends/Interest/Earnings/Investment
Retirement Pension Salary/Wages
Farms/Hacienda/Fishpond Remittance from abroad/Commission
Real estate rental Others
Practice of Profession
WHO CONTRIBUTES FOR YOUR SCHOOL EXPENSES? HOW MUCH?
DOES YOUR FAMILY OWN OR RENTS THE HOUSE YOU LIVE? PLEASE PLACE A CHECK MARK BELOW:
Own House (not mortgaged)
Own House (Mortgaged); Monthly Amortization PHp
Renting: Monthly Rental Php
Neither own nor rent the house
Name of Owner
Relationship of owner to family
III FAMILY DATA
Parents/Legal Guardians
Name of Family Member Civil School Annua
Highest Degree Present
Status Attended Name of l
/level Job
of / Employer Gross
reached Designati
Siblings Graduate Incom
on
d e
(Father)
(Mother)
(Legal Guardian)
(Brothers/Sisters)
IV STATEMENT OF THE APPLICANT
I hereby certify that all the data and information which I have furnished are accurate and complete. I understand that any false
data given , misinterpretation and concealment of material facts and/or withholding any relevant information will automatically
disqualify me from receiving any financial assistance from the Province of La Union.
Moreover, I understand that the scholarship Committee may send a fact-finding team to visit my home/residence to verify the
veracity of the information provided in this application and will give my utmost cooperation in this regard.
Applicant's Signature
STATEMENT OF THE APPLICANT'S PARENTS OR GUARDIAN
I hereby certify to the truthfulness and completeness of the information which my son/daughter/dependent has furnished in
this application together with all the documents attached. I further recognize that in signing this application form, I share with my
son/daughter/dependent the responsibility for the truthfulness and completeness of the information supplied herein.
Parent's/Legal Guardian's Signature
APPROVED:
MARIO EDUARDO C. ORTEGA, MDA
Provincial Governor
ACTION TAKEN BY SCHOLARSHIP COMMITTEE:
REMARKS
