Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cabanatuan City

OFFICE OF STUDENTS AFFAIRS

APPLICATION FOR
DEPARTMENTAL/CAMPUS LEADERSHIP AWARD

Personal information:
NAME:
Last name First name Middle name
STUDENT NUMBER:___________________________
GENDER: Male Female AGE:________
COURSE:____________________________________________________________________
COLLEGE: __________________________________________________________________
CAMPUS:____________________________________________________________________

General Criteria
I. Extra-curricular Activities:
A. Membership in any Relevant Organization
1. Level
 Departmental - 2.0 pts.
 Class - 1.0 pt.

Level
Organization (Departmental, Year Position Activities Rating
Class)

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 B. Awards and Recognitions:
1. Level
 National - 2.0 pts.
 Regional - 1.0 pt.
 Local/Institutional - 0.5 pt.

Level
Award/s
(National,
Regional, Local, Rating
(From A.Y.
2018-2019, 2017-2018, 2016-2017, 2015-2016, 2014-2015) Institutional)

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 C. ACCOMPLISHMENT/S:
I. Nature of Activity II. Leadership Role:
 Educational - 2.0 pts.  Leader/Coordinator - 2.0 pts.
 Social/Cultural - 2.0 pts.  Organizer/Committee Chair - 1.5 pts.
 Physical Development - 1.0 pt.  Supportive/Committee member - 1.0 pt.
 Moral/Spiritual - 1.0 pt.  Participants - 0.5 pt.

Level of Activity
(National, Nature of Leadership
Programs/Activities/Projects/Training Activity
Date Rating
Regional, Local, Role
and Seminars Institutional)

Requirements:

1. Endorsement Letter by the Dean/Campus Director/Unit Head.

2. Certificate of Grades (COG) and GPA from the Registrar.
3. Certificate/s of Membership from Relevant Organizations.
4. Plaque/s of Appreciation/Certificate of Recognition/Appreciation.

I hereby certify that all information are true and correct to the best of my knowledge.

____________________________________________
Signature over Printed Name of Applicant

Date Signed: ____________________

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