GO-EDUC4-01

Rev. 04
Republic of the Philippines
PROVINCE OF ILOCOS SUR
Heritage City of Vigan Recent
1.5 x 1.5 ID Picture
ILOCOS SUR EDUCATIONAL Taken within the
ASSISTANCE & SCHOLARSHIP last 3 months
(White/Red Background)
PROGRAM APPLICATION FORM 1

Control No.
Instructions: Date of Filing JULY 14, 2022
1. Print all entries
2. Place (X) in the appropriate space provided

All photocopied documents should be faithful reproduction of the original. Bring the original copies of the documents for validation purposes.
Fill up ALL the data requirements in the Application Form and submit ALL the documents required during the Application. Incompletely fille
Submit Application Form at the E.S.A. Secretariat.
Please do NOT wait for the last day of the application period if you do not want to be inconvenienced, or worse rejected.

Requirements:
Certification from the Barangay Chairman that the
applicant is a bonafide resident of the barangay for
at least one (1) year and has no derogatory
record/s.
Copy of latest grades with General Average of 2.25
or 83%.
Two (2) Copies of 1.5” x 1.5” picture taken within
the last three (3) months with WHITE background.
Print your name at the back of each photo and affix
your signature above your name.
Photocopy of Latest Income Tax Return of Parents or
Certification of Exemption from the Bureau of Internal
Revenue (BIR) stating the annual gross income. If
Parent/ Legal Guardian is a retired employee, submit
retirement form and/or pension voucher. If parents are
not filing income tax, acquire a Certificate of Indigency
from your barangay of residency.
Copy of Certificate of Good Moral Character

A. PERSONAL BACKGROUND
Surname: First Name: Middle Name: Ext.(e.g. Jr., III)
GALOPE ANGELIKA KATE DE LA CRUZ
Permanent Address:
SITIO LIMMANSANGAN, MARGAAY, NARVACAN, ILOCOS SUR
Present Address:
SITIO LIMMANSANGAN. MARGAAY, NARVACAN ILOCOS SUR
Birthdate: (mm/dd/yyyy) Age: Sex: Civil Status: Religion: Contact No:
OCTOBER 16, 2003 18 FEMALE SINGLE ROMAN CATHOLIC 0992-677-2843

Course/Course Preference: Year Level: GWA (last SEM)

BACHELOR OF SCIENCE IN HOSPITALITY MANAGEMENT FRESHMAN 92
School/College/University Preference:
Ilocos Sur Community College X Ilocos Sur Polytechnic State College
Main Campus Demofarm X Sta. Maria Campus Tagudin Campus
University of Northern Philippines Cervantes Campus Narvacan Campus
North Luzon Philippines State College Candon City Campus Santiago Campus
Are you a recipient or have applied for another Scholarship other than this? YES NO
 If YES, please specify the nature of the other Scholarship Grant: X
B. EDUCATIONAL BACKGROUND
Year Honors/Awards
Name of School School Address
Graduated Received (If any)
Secondary PARATONG, NARVACAN, ILOCOS SUR 2022 WITH HONOR
NARVACAN NATIONAL CENTRAL HIGH
SCHOOL
Elementary LIMMANSANGAN, NARVACAN, ILOCOS SUR 2016 GIRL SCOUT
NARVCAN NORTH CENTRAL SCHOOL

C. FAMILY BACKGROUND
Father Mother
X Living Deceased X Living Deceased
Guardian
Name ROBERT GALOPE SHIRLY GALOPE
Occupation TRICYCLE DRIVER MANICURIST @ JUN E SALON
Place of Work NARVACAN NARVACAN MALL
Highest Educational Attainment COLLEGE GRADUATE VOCATIONAL GRADUATE
Contact No. 09916939806 09916939805
Ave. Monthly Income 5,000-8,000 5,000-11,000

ESA Form 001

 Numbers of siblings in the family: ( 2 ) Please fill out information below about your siblings.
Highest Educational Highest Educational
Name of Brother/s Age Name of Sister/s Age
Attainment Attainment
ROSHELLE MAE GALOPE 19 COLLEGE STUDENT

Do you have any brother / sister who is also a recipient of the Ilocos Sur Educational Assistance and Scholarship Program?
YES NO If YES, state the Name, Year & Course and School where he/she is currently enrolled as scholar

STATEMENT OF APPLICANT

I hereby certify to the veracity of all information I have provided. I understand that any false disclosure,
misinterpretation, concealment of material facts and / or withholding any relevant information will be tantamount to
disqualification from the Scholarship Program of the Provincial Government of Ilocos Sur.
Moreover, I understand that the Scholarship Committee may send a fact-finding team to visit my home / residence to
verify the truthfulness of the information provided in this application and I will give my utmost cooperation in this regard. I
understand that my refusal to comply with any of these herein stated terms and conditions may mean disqualification or
withdrawal of Scholarship Grants & Privileges.

JULY 14, 2022 ANGELIKA KATE D. GALOPE

Date:
Applicant’s Signature over Printed Name

STATEMENT OF APPLICANT’S PARENTS / GUARDIAN

I hereby verify to the truthfulness and completeness of the information which my son / daughter / dependent has
furnished in this application together with all the documents attached. I further recognized that in signing this application form,
I share my son / daughter / dependent the responsibility for the truthfulness and completeness of the information provided
herein.
Moreover, I understand that the Scholarship Committee may send a fact-finding team to visit my home / residence to
verify the truth of the information provided in this application and I will give my utmost cooperation in this regard. I
understand that my refusal to comply with any of these herein stated conditions may mean disqualification or withdrawal of
Scholarship Grants & Privileges due to my son / daughter / dependent.

Date: JULY 14, 2022 ROBERT GALOPE

Parent/Guardian’s Signature over Printed Name

Received by: Reviewed by: Recommending Approval:

ESA Secretariat In-charge Chairman

Date: Education and Scholarship Affairs Committee on Education

Approved by:

Governor

Important Notice:
1. Scholarship privilege will be withdrawn from an applicant who withhold and/or falsifies information.
2. For old or continuing scholarship grantees, be sure to participate / take part in the different programs or activities of the
Provincial Government at least two for every semester.
3. Upon enrolment, submit a photocopy of your ENROLMENT FORM. Failure to submit means cancellation of applicant's name
in the Provincial Scholars Master list.