GSIS-STI EDUCATIONAL ASSISTANCE APPLICATION FORM

For GSIS Members, Pensioners or Qualified Dependent

NAME OF STUDENT STI CAMPUS SCHOOL YEAR/TERM

Family Name Given Name Middle Name

ADDRESS

House/Lot/Unit No. Street Subdivision/Village/Building Barangay City/Municipality Province

GENDER AGE BIRTHDAY

(MM - DD - YYYY)

PERSON TO CONTACT IN CASE OF EMERGENCY

Family Name Given Name Middle Name Contact No.

Address

CLASSIFICATION

NAME OF GSIS MEMBER

GSIS Member GSIS Pensioner

GSIS Dependent of: UMID CARD NUMBER

Specify relationship with UMID card holder

GSIS Member GSIS Pensioner

We hereby certify that all the data and information that we have furnished in this application, together with all the documents attached, are true,
accurate, and complete. We understand that any misinformation and/or witholding of information will automatically disqualify us from receiving any
scholarship grant, financial assistance, or subsidy, and may serve as ground for expulsion from the school, without prejudice to the filing of charges
and other legal actions against us. If any misinformation or witholding of information on our part is discovered after the awarding of any form of
scholarship grant, dinancial assistance, or subsidy, we shall pay the entire amount of tuition and laboratory fees which were granted to me as a partial
scholarship grant from the first day of tenure as an STI student, without prejudice to the filing of charges against us.

Applicant’s signature GSIS UMID Card Holder’s Signature

Signature above printed name Signature above printed name

ATTACHMENT
For dependents of GSIS Member/Pensioner For GSIS Member/Pensioner

1. GSIS UMID card, subject to verification 1. GSIS UMID card, subject to verification
2. Photocopy of GSIS UMID card with signature 2. Photocopy of GSIS UMID card with signature of card holder
3. Certification duly signed by the GSIS UMID card holder that
attests to the level of consanguity/affinity
4. Notarized certification (Affirmation and Undertaking)
5. Duly signed GSIS-STI Educational Assistance Program Scholarship Contract
GSIS-STI EDUCATIONAL ASSISTANCE APPLICATION FORM
For Qualified Survivors of GSIS Members or Pensioners

NAME OF STUDENT STI CAMPUS SCHOOL YEAR/TERM

Family Name Given Name Middle Name

ADDRESS

House/Lot/Unit No. Street Subdivision/Village/Building Barangay City/Municipality Province

GENDER AGE BIRTHDAY

(MM - DD - YYYY)

PERSON TO CONTACT IN CASE OF EMERGENCY

Family Name Given Name Middle Name Contact No.

Address

NAME OF DECEASED GSIS MEMBER GSIS UMID CARD NO. (if available)

Family Name Given Name Middle Name

RELATIONSHIP WITH GSIS MEMBER

I hereby certify that all the data and information that I have furnished in this application, together with all the documents attached, are true, accurate,
and complete. I understand that any misinformation and/or witholding of information will automatically disqualify me from receiving any scholarship
grant, financial assistance, or subsidy, and may serve as ground for expulsion from the school, without prejudice to the filing of charges and other legal
actions against me. If any misinformation or witholding of information on my part is discovered after the awarding of any form of scholarship grant,
financial assistance, or subsidy, I shall pay the entire amount of tuition and laboratory fees which were granted to me as a partial scholarship grant from
the first day of tenure as an STI student, without prejudice to the filing of charges against us.

Applicant’s Signature
Signature above printed name

ATTACHMENT

1. Certification/authentication of membership issued by GSIS Regional office

2. Duly signed GSIS-STI Educational Assistance Program Scholarship Contract