PGO-INB-F01-02

APPLICATION DATE: M M D D Y Y Y Y

APPLICATION FORM

RECENT
PHOTO
2x2

1 SURNAME FIRST NAME MIDDLE NAME 2 SEX 3 CIVIL STATUS

MALE SINGLE WIDOWER/WIDOW
FEMALE MARRIED SEPARATED
4 If Married, Write Maiden Name 5 NAME OF SPOUSE Occupation

6 DATE OF BIRTH 7 PLACE OF BIRTH

8 HEIGHT (Meters ) 9 WEIGHT (Kilos ) 10 BLOOD TYPE

11 ADDRESS (House No./Street ) (Baranggay) :
(Municipality ) (Province ) 12 RELIGION

13 CELLPHONE NO. 14 TEL. NO. (Landline )

15 FACEBOOK ACCOUNT 16 E-MAIL ADDRESS

17 NAME OF FATHER
LAST NAME FIRST NAME MIDDLE NAME 18 DATE OF BIRTH 19 CELLPHONE NO. Occupation

20 ANNUAL INCOME:
21 NAME OF MOTHER
LAST NAME FIRST NAME MIDDLE NAME 22 DATE OF BIRTH 23 CELLPHONE NO. Occupation

24 ANNUAL INCOME:
25 GUARDIAN (In cases of Deceased Parents )
LAST NAME FIRST NAME MIDDLE NAME 26 DATE OF BIRTH 27 CELLPHONE NO. Occupation

28 ANNUAL INCOME:
29 OTHER FAMILY MEMBERS
Name Relationship Date of Birth Name Relationship Date of Birth
1 4
2 5
3 6
v
30 EDUCATION Name of School Year Graduated Course / Honors Received

ELEMENTARY
HIGH SCHOOL
COLLEGE (if any)
I'm currently enrolled at: SCHOOL: YEAR:
COURSE: Regular? Yes No
31 Are you a WORKING STUDENT? Yes No (If Yes, please fill up the necessary fields below )
Date Started Position Department / Agency Monthly Salary Status of Appointment

(continue on separate sheet if necessary)

32 Special Skills:

33 Other Qualifications (Include membership in related associations, hobbies, etc. )

34 I hereby declare under oath that the information given above are true and correct to the best of my personal knowledge.

Signature Right Thumbmark

Remarks (for interviewer only ): Average:

Endorsed by:


ACKNOWLEDGEMENT RECEIPT

LASTNAME APPLICATION DATE M M D D Y Y Y Y

This is to acknowledge receipt of your application for your scholarship.
FIRST NAME

MIDDLE NAME
RECEIVED BY: (SIGNATURE OVER PRINTED NAME)
 THIS APPLICATION FORM IS NOT FOR SALE

Date of Submission: April 1 - 30

During Office Days & Office Hours

COLLEGE SCHOLARSHIP PROGRAM

CRITERIA FOR THE SELECTION OF NOMINEES FOR SCHOLARSHIP

1. High school graduate

2. A permanent resident of Bataan
3. Has a good moral character
4. Can communicate in both Filipino and English
5. Admitted for enrollment in any college or university inside or outside of Bataan

REQUIREMENTS TO BE SUBMITTED TO THE SCHOLARSHIP COMMITTEE

1. Application Form
2. Letter of intent for applying Iskolar ng Bataan
3. Two (2) pcs. 2X2 Recent Colored Picture
4. Comelec ID/ Registration / Certification of Parents Brothers and/or Sisters of
voting age
5. For High School: Photocopy of Report Card (Form 138) duly certified by the
high school principal with minimum average of 80%
6. For College: 1st Semester & 2nd Semester Latest Grades with minimum
average of 2.50
7. Photocopy of Birth Certificate

Note: This Scholarship Grant is for students who will be:

(1) High school graduates and

(2) Admitted to any college or university (inside or outside of Bataan)
regardless of year level.