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Republic of the Philippines

City of Santiago within the last 6
Office of the City Mayor
LOCAL LITERACY COORDINATING COUNCIL OFFICE months
City Hall Compound, San Andres, Santiago City
Email: SantiagoCityLiteracy@gmail.com facebook: fb.com/SantiagoCityLiteracy Mobile: 0906-638-5705 (2 X 2)
KAISAKA SA EDUKASYON AT LITERASIYA
HIGHER EDUCATION SUPPORT PROGRAM APPLICATION FORM
Instructions: WRITE IN PRINT (UPPERCASE). MARK APPROPRIATE BOXES WITH CHECK (√)

I. PERSONAL INFORMATION
LAST NAME:
FIRST NAME:
MIDDLE NAME:
DATE OF BIRTH: PLACE OF MALE
____/_______/_________ AGE: SEX: FEMALE
(mm/dd/yyyy) BIRTH:
CIVIL STATUS: SINGLE WIDOWED
SEPARATED MARRIED
HOUSE NO. BLOCK NO. SUBDIVISION
If Married, Full Name of Spouse:
PUROK STREET BARANGAY
RESIDENTIAL
________________________
ADDRESS: SANTIAGO CITY 3311
CITY ZIP CODE
CITIZENSHIP: PRECINT NO.

RELIGION: DEGREE/
MOBILE NO: COURSE:
EMAIL : (WRITE IN FULL)

FACEBOOK: YEAR LEVEL: 1st Year 2nd Year 3rd Year 4th Year 5th Year

INSTAGRAM: TWITTER: STUDENT ID:

OTHER SOCIAL MEDIA ACCOUNTS: SCHOLARSHIP STATUS: OLD NEW
Academics Leadership Sports Speaking Debate Writing
TYPE OF
Arts Music Song Dance Acting Goodwill Ambassadors
SCHOLARSHIP: Information & Communication Technology & Ambassadress
II. FAMILY BACKGROUND
FATHER MOTHER
LAST NAME: SURNAME:
FIRST NAME: FIRST NAME:
MIDDLE NAME: MIDDLE NAME:
OCCUPATION: OCCUPATION:
AGE: AGE:
III. EDUCATIONAL BACKGROUND
INCLUSIVE
NAME OF SCHOOL YEAR UNITS YEARS HONORS
LEVEL
(Write in full) GRADUATED EARNED RECEIVED
FROM TO
PRIMARY:
SECONDARY:
TERTIARY:

I certify that I have personally accomplished this form which is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the
City Government of Santiago. I agree that any misrepresentation made in this document and its attachments shall invalidate my application.

___________________________________________ ________________________
Signature over Printed Name Date

This portion is to be filled up by the Local Literacy Coordinating Council Secretariat.

Checked and Verified by:
Initial Requirements:
APPLICANT NO.: 202___ - ___________
 Certificate of Grades (Latest) / Report Card
 Assessment/Enrolment Form (Original & Photocopy)
_____________________________  Voter’s Certification/ ID - Applicant & Both Parents (Original & Photocopy)
Signature over Printed Name Academic Non-Academic  Certificate of Residency – Applicant & Both Parents (Original & Photocopy)
 School ID (Original & Photocopy)

Date:

Remarks:_______________________________________________________
Remarks:______________________

APPROVED FOR SCHOLARSHIP AT: