PROVINCE OF ANTIQUE

OFFICE OF THE GOVERNOR

Provincial Youth Development Office

PROVINCIAL GOVERNMENT EDUCATIONAL ASSISTANCE

APPLICATION FORM
Control No. _________
PWD IP

NAME: _____________________, _____________________, ________________SEX: _______ AGE: _______

Surname Given Name Middle Name

ADDRESS: _____________________, __________________DATE OF BIRTH: ___________________

Barangay Municipality mm/dd/yy

Civil Status: _______________ Mobile No.: _____________ Email Address.: __________________________

Facebook Account: ________________________ SCHOOL: _______________________________

COURSE: _____________________________YEAR & SECTION: _____________STUDENT ID NO._________

SEMESTER: 1st, 2nd ACADEMIC YEAR: _______________

Father’s Name: ________________, _______________, _______________ Occupation: _________________

Surname Given Name Middle Name

Mother’s Maiden Name: _______________, _______________, _______________ Occupation: ____________

Surname Given Name Middle Name

Parent’s combined Annual Income: ____________________________________ (ITR/Estimated Income)

Mother’s Contact No. ____________________

Father’s Contact No. _____________________

Date of Contract Signing:

Validated by:

Signature over printed name

Student
Checklist of Documentary Requirements

_______ Registration Form with Complete Signatures

_______ Photocopied Validated School ID (SY: 2022-2023) 1st Semester (Old Students)
_______ Colored Photocopy of PSA for incoming 1st year students
_______ Certificate of Indigency
_______ Report of Ratings/Summary of Grades (previous semester)
_ _______________________________________________________

Control No. ______

Date: ___________
NOTES
1. Compile all the required documents along with the application form in a long-sized brown envelope.
2. School documents with certified true copy by the school registrar.
3. Certificate of Indigency issued by the Barangay. The same certificate should come from the permanent address indicated in the school
registration form.
4. No failing grades, but must have completed the subjects as indicated in the RF (if the student applicant has been enrolled to thesis writing, a
statement or certification from the university stating that the above-mentioned subject is in progress and must be complied within 1 year).
5. Certification not enjoying any National and Regional Scholarship program from the school or university. (Exemption is hereby granted to first
year students for the first semester only.)

This serves as proof that we have received your application for educational assistance for ______ semester of Academic Year _______.
If you have questions and concern you may contact PYDO Tel No. 036-540-2542

FULL NAME: ________________________________________________________________

ADDRESS: ___________________________________________________________________
VALIDATED BY: __________________________________________________________

2nd floor, ANIAD building, New Capitol Grounds

San Jose de Buenavista, Antique 5700 Philippines
pydevelopmentofficeantique@gmail.com | Facebook.com/antiqueprovincialyouthaffairs
 PROVINCE OF ANTIQUE
OFFICE OF THE GOVERNOR
Provincial Youth Development Office

2nd floor, ANIAD building, New Capitol Grounds

San Jose de Buenavista, Antique 5700 Philippines
pydevelopmentofficeantique@gmail.com | Facebook.com/antiqueprovincialyouthaffairs