CHED-TDP Form ANNEX "A"

2019 version (NOT FOR SALE)

Office of the President of the Philippines
COMMISSION ON HIGHER EDUCATION
REGIONAL OFFICE ____
2 X 2 ID
PICTURE

CHED TULONG DUNONG PROGRAM (CHED-TDP)

APPLICATION FORM
Instructions: Read General and Documentary Requirements. Fill in all the required information. Do not leave an item blank. If item is not applicable, indicate "N/A".

GENERAL QUALIFICATION REQUIREMENTS per Section 6 of the Joint Memorandum DOCUMENTARY REQUIREMENTS per Section 7.2 of the Joint Memorandum
Circular No. ___ Circular No.____
Academic Requirements:
1 Filipino citizen; a. For Incoming Freshmen students eligible for college – high school report card;
2 High school graduates; or college students with earned units in CHED-recognized programs of Private b. For Applicants with Earned Units in college in CHED-recognized programs of Private HEIs and
SUCs/LUCs with COPC – duly certified true copy of grades for the latest semester/term attended c.
HEIs, SUCs or LUCs with COPC with at least a passing general weighted average (GWA); or passer of
3 With combined annual gross income of parents/guardian which shall not exceed Four Hundred For Other Applicants:
Thousand Pesos (PhP400,000.00). ALS - duly certified copy of ALS Accreditation and Equivalency Test Passer Certificate; and
PEPT - duly certified copy of PEPT Certificate of Advancing to the Next Level Income
Requirements - whichever is applicable :
NOTE: Applicant shall not avail of any national government-funded assistance, except for FreeLatest Income Tax Return and Bureau of Internal Revenue Form 2316 for fixed income earners of parents/guardian, if
employed; Certificate of Tax Exemption from the BIR of parents/guardian, if not employed; Certificate of Indigence from
Higher the Barangay concerned; Certificate of Indigence/Case Study from the Department of Social Welfare and Development;
Education in SUCs and LUCs under RA 10931, the “UAQTE Act of 2017.” or Latest copy of contract or proof of income, for the children of Overseas Filipino Workers and seafarers.

PERSONAL INFORMATION

1. Name
MORTEL APHOL JOYCE B. N/A
(Last Name) (First Name) (Middle Name) (Extension
Name)
2. Date of Birth (mm/dd/yy)
DECEMBER 16, 2000 9. Permanent Address
(Street/Brgy., Town/City, Province)
BUTONG TAAL BATANGAS
3. Place of Birth
Butong Taal Batangas
10. Zip Code
4. Sex Male / Female 4208 11. District
1
/ Single Widowed
9. Permanent Address
(Street/Brgy., Town/City, Province)
BUTONG TAAL BATANGAS
5. Civil Status Married Separated
10. Zip Code
Annulled Others 4208 11. District
1
6. Citizenship
FILIPINO 11. Name of School Last Attended
BATANGAS STATE UNIVERSITY MAIN I
7. Mobile Number
09455598286 12. School Address 12 RIZAL AVE., POBLACION, BATANGAS, 4200
BATANGAS
8. E-mail Address
apholjoycemortel16@gmail.com
13. School Sector: ( / )Public ( )Private 14. Learner Reference Number (LRN)
19-56186
15. Highest Attained Grade (Year Level) 16. Type of Disability (if applicable)
N/A
2nd YEAR COLLEGE
17. IP affiliation (if applicable)
N/A
FAMILY BACKGROUND
Father: ( / ) Living ( )Deceased Mother: ( / ) Living ( ) Deceased Legal Guardian

18. Full Name (including middle name) APOLINARIO LEGASPI MORTEL LORIE JANE BILALE MORTEL LORIE JANE BILALE MORTEL
19. Address
BUTONG, TAAL, BATANGAS BUTONG, TAAL, BATANGAS BUTONG, TAAL ,BATANGAS
20. Contact Number
09106749529 09553443036 09553443036
21. Occupation
FISHERMAN N/A N/A
22. Name of Employer
N/A N/A N/A
23. Employer Address
N/A N/A N/A
24. Total Parents Annual Gross Income
P50,000-70,000 N/A N/A
25. Number of siblings
3
26. School Intended to enroll or enrolled in:
BATANGAS STATE UNIVERSITY MAIN I
27. School Address:
28. Type of School:
12 RIZAL AVE., POBLACION, BATANGAS, 4200 BATANGAS
( / ) Public ( ) Private
29. Degree Program:
BS in ACCOUNTANCY
________________________________________________________________
Type Grantee Institution/Agency
30. Are you enjoying other sources of educational/financial assistance? ( ) Yes or ( / ) No If yes, please specify 1. N/A N/A .
2. N/A N/A .
I hereby certify that foregoing statements are true and correct. Any misinformation or witholding of information will automatically disqualify me from the CHED-Tulong Dunong Program. I am willing to
refund the financial benefits received if such information is discovered after acceptance of the award.
I hereby express my consent for the Commission on Higher Education to collect, record, organize, update or modify, retrieve, consult, use, consolidate, block, erase or destruct my personal data as
part of my information. I hereby affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my personal data and be indemnified in case of damages pursuant to the
provisions of the Republic Act No. 10173 of the Philippines, Data Privacy Act of 2012 and its corresponding Implementing Rules and Regulations.

MORTEL, APHOL JOYCE B. MAY 22, 2021

(Signature over Printed Name of Applicant) Date Accomplished

Note: Fully accomplished form to be submitted to the CHEDRO
DO NOT FILL-OUT THIS PORTION (FOR CHED USE ONLY)
Belongs to: (any of the following groups) Documents Attached:
dependent of solo parent senior citizens 1. Academic
persons with disabilities please specify type of disability_________________ indigenous and ethnic peoples, ( ) Report Card ( ) Copy of Grades: Grade 11 or 1st semester of Grade 12 2.
please specify membership ____________________ Financial
( ) ITR ( ) Tax Exemption ( ) Certifcate of Indigency
( ) Case Study DSWD ( ) OFW Contract
3. Others
( ) Solo Parent ( ) Senior Citizen ( ) IPs ( ) PWD ( ) 4Ps

Evaluated/Processed by:

CHED StuFAP Coordinator