PGO-INB-F01-03 Revised February 2020 APPLICATION DATE: 1M 0

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APPLICATION FORM

RECENT
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1 SURNAME FIRST NAME MIDDLE NAME 2 SEX 3 CIVIL STATUS

TUPPAL JAN LESTER BALALA ✔ MALE ✔ SINGLE WIDOWER/WIDOW
FEMALE MARRIED SEPARATED
4 If Married, Write Maiden Name 5 NAME OF SPOUSE Occupation
N/A N/A N/A
6 DATE OF BIRTH OCTOBER 26, 1999 7 PLACE OF BIRTH MARIVELES, BATAAN
8 HEIGHT (Meters ) 1.55 meters 9 WEIGHT (Kilos ) 69 kilograms 10 BLOOD TYPE O+
11 ADDRESS (House No./Street ) BLDG 10, RM 8 CDA (Baranggay) : MALAYA
(Municipality ) MARIVELES (Province ) BATAAN 12 RELIGION JEHOVA'S WITNESSES

13 CELLPHONE NO. 09054354925 14 TEL. NO. (Landline ) N/A

15 FACEBOOK ACCOUNT JAN LESTER BALALA TUPPAL 16 E-MAIL ADDRESS mrlester.tuppal@gmail.com

17 NAME OF FATHER
LAST NAME FIRST NAME MIDDLE NAME 18 DATE OF BIRTH 19 CELLPHONE NO. Occupation
11/14/1974 09380868257 TRICYCLE DRIVER
TUPPAL JUANITO BASSIG
20 ANNUAL INCOME: BELOW 100,000
21 NAME OF MOTHER
LAST NAME FIRST NAME MIDDLE NAME 22 DATE OF BIRTH 23 CELLPHONE NO. Occupation
12/07/1972 09452315962 FACTORY WORKER
BALALA HANANE APDAN
24 ANNUAL INCOME: BELOW 100,000
25 GUARDIAN (In cases of Deceased Parents )
LAST NAME FIRST NAME MIDDLE NAME 26 DATE OF BIRTH 27 CELLPHONE NO. Occupation
N/A N/A N/A
N/A N/A N/A
28 ANNUAL INCOME: N/A
29 OTHER FAMILY MEMBERS
Name Relationship Date of Birth Name Relationship Date of Birth
1 JEHUWYN TUPPAL BROTHER 12/09/2003 4 N/A
2 N/A 5 N/A
3 N/A 6 N/A

30 EDUCATION Name of School Year Graduated Course / Honors Received

ELEMENTARY BEPZ ES 2013 N/A

HIGH SCHOOL MNHS-MALAYA 2016 N/A
SENIOR HIGH SCHOOL SOFTNET ITC 2018 WITH HONORS

COLLEGE (if any) N/A N/A N/A

I'm currently enrolled at: SCHOOL: N/A YEAR: N/A

COURSE: N/A 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

N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A
(continue on separate sheet if necessary)
32 Special Skills: FLEXIBLE, RESPONSIBLE, WILLING TO LEARN, MATH, COURTEOUS
33 Other Qualifications (Include membership in related associations, hobbies, etc. ) PLAYING BASKETBALL
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 1 M0 D0 6

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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. Incoming freshmen college and/or college student

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. Photocopy of COMELEC ID/Registration/Certification of both Parents
5. For Incoming Freshmen College: Photocopy of Report Card (Form 138) duly
certified by the school registrar with minimum average of 80%
6. For College: Certified True Copy of the Latest Grades with minimum average
of 2.50
7. Photocopy of Birth Certificate

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

(1) Incoming freshmen college and/or;

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