Annex A

REPUBLIC OF THE PHILIPPINES

PROVINCE OF NUEVA ECUA
MUNICIPALITY OF GUIMBA

GUIMBA KONG MAHAL EDUCATIONAL ASSISTANCE PROGRAM (GKM-EAP)

APPLICATION FORM

Instructions: Fill in the required information in handwriting. DO NOT LEAVE an item blank. If the item is not
applicable, indicate “N/A”. All applications must be accomplished and filled PERSONALLY by the applicant. Please
write legibly.

I. PERSONAL INFORMATION
A. Surname:
B. Given Name: ID PHOTO
C. Middle Name:
D. Date of Birth: (month/day/year):
E. Age (at the time of filing):
F. Street/Purok: Taken within six (6) months
G. Barangay: prior to filing of application
H. Active Mobile Number:
I. Active Email Address:
II. EDUCATION
A. Name of School:
B. School Address:
C. Year Level:
Degree:
D. Educational Assistance Availed/Awarder for the current semester/academic year. Indicate if SPES
Beneficiary.
1. Title of Educational Assistance:
2. Awarder:

I hereby certify that all the information stated above are personally accomplished, correct and true.
__________________________________________________________________________________ _______________________________________________
Signature above printed name of the student Date Accomplished

To be processed by the screening committee:

a. Photocopy of Documentary Requirements:
Citizenship:
Birth Certificate (NS0, PSA)
Barangay Certificate of Residency of the student
Barangay Certificate of Residency of Parent
Academic Requirements
Report Card/Certificate of Grades from the latest semester attended with grading equivalence if
Grade point scale (4.00— 1.00) or Letter grade system (A-D):
Proof of Enrollment for the current semester
Financial Documents-any of the following:
Latest Income Tax Return (ITR) of parent or guardian
Certificate of Tax Exemption from the Bureau of Internal Revenue (BIR)
Latest copy of contract or proof of income may be considered for children of Overseas Filipino Workers
(OFW) and seafarers
Certificate of Employment of both parents

Processed by:

Signature above printed name Date Received