Republic of the Philippines

PROVINCE OF CAPIZ
OFFICE OF THE GOVERNOR
CAPIZ PROVINCIAL SCHOLARSHIP AND
EDUCATIONAL ASSISTANCE PROGRAM
Capiz Provincial Capitol, Roxas City
Application No.: 2020 - ___________ Tel. No. 522-2199

CAPIZ SCHOLARS
APPLICATION FORM
2x2
1. Name: ______________________________________________________________ Picture
Last Name First Name Middle Name

2. Permanent Address: __________________________________________________ (white background)

NO Filter please
3. Date of Birth: __________________ 4. Civil Status: __________________
Not Scanned picture
5. Age: _______ 6. Sex: ___________ 7. Place of Birth: ________________
8. Nationality: ________________________ 9. Religion: _____________________
10. Contact No.: ______________ 11. Email Address: _______________________
12. Father’s Name: ______________________________________________________
Last Name First Name Middle Name
Date of Birth: ______________________ Occupation: _________________ Contact No.:_________________
Citizenship: ____________ Educational Attainment: _________________ Net Monthly Income: ________________
13. Mother’s Maiden Name: ____________________________________________________________________________
Last Name First Name Middle Name
Date of Birth: ______________________ Occupation: _________________ Contact No.:_________________
Citizenship: ____________ Educational Attainment: _________________ Net Monthly Income: _________________
14. Preferred School/College/University: _________________________________________________________________
Preferred Course to be taken: 1st Choice: ______________ 2nd Choice: ____________ 3rd Choice: ____________
15. Name of Sibling/s Date of Birth Education/Profession/Occupation
_________________________________ __________________ ____________________________
_________________________________ __________________ ____________________________
_________________________________ __________________ ____________________________
_________________________________ __________________ ____________________________
_________________________________ __________________ ____________________________
16. Educational Background
Highest
Last School
Name of School Address/Location Year Attended Academic Honor
Received
Elementary

Junior High

Senior High
Course Taken
College

17. How do you rate your health condition? Excellent Good Fair Poor
18. Names and address of three (3) persons, NOT related to you, who know you personally and can give information about you.
Name Address/Profession Contact/Cellphone No.
1. _______________________________ _________________________ ______________________
2. _______________________________ _________________________ ______________________
3. _______________________________ _________________________ ______________________
APPLICANT’S CONTRACT
I hereby certify that the foregoing information provided in this application form for Provincial Scholarship Program of the Provincial
Government of Capiz are true and correct to my own knowledge and belief. I further bind myself, if granted the scholarship of the
Provincial Government to obey and comply with the Implementing Rules and Regulations prescribed by the Provincial Government
Scholarship Program Committee.

___________________________________ ___________________________________
Signature over Printed name of Applicant Signature over Printed name of Parent/Guardian

_____________________
Date
 CSEAP Scholarship Eligibility and Qualifications

 A Registered voter of Capiz or the parents are registered voters of Capiz.

 A bonafide resident of Capiz for at least one (1) year prior to the filing of application for
the scholarship grant and with no derogatory records.
 Belongs to a family whose gross annual income does not exceed Two Hundred thousand
Pesos (P 200,000.00).
 A graduate of any public or private school in Capiz who seek to pursue college or
technical vocational education and is not currently enjoying any other scholarship grant
or privilege from any public or private institution.

Documentary Requirements (to be submitted after passing the written and oral examination)

 Duly accomplished application form with attached two (2) 2x2 picture with white
background.
 Certified machine copy of parent’s W2/ITR (Income Tax Return) or Original BIR
Certification of Tax Exemption. In case of deceased parents, Death Certificate shall
be attached.
 Certified machine copy of high school report cards or registration form (RF).
 Barangay Clearance (Residency and good moral character).
 Drug Testing Certificate from drug testing centers duly accredited by the national or
local government
 Authenticated Certificate of Live Birth
 Letter addressed to the Governor applying for a Scholarship Grant.

Checked by:

_______________________________
Scholarship Secretariat Staff
Date: _________________

Verified by:

ENGR. ROVIL A. VILLASOTO, LPT

Provincial Scholarship Coordinator