Republic of the Philippines

Office of the President

Philippine Space Agency

SCHOLARSHIP PROGRAM APPLICATION FORM

(To be submitted with attachments)

TYPE OF SCHOLARSHIP APPLIED FOR

Choose one of the following:

Local
International

Choose one of the following:

Full support. Indicate no. of years and months: _________________
Partial support. Indicate no. of years and months: ________________

TYPE OF DEGREE
Masters Doctoral

Name of Applicant: _________________________________________________________________________________

Last Name First Name Middle/Maiden Name

Title of Course and University: ________________________________________________________________________

Qualifications

MS and Ph.D. Scholarships:

1. Must have a Bachelor’s Degree (for masters scholarship) or Master’s Degree (for doctoral scholarship) in a
relevant discipline
2. Must be a Filipino citizen
3. Must not be over 45 years of age at the start of the program
4. Must have a BS degree in a space science or engineering-related field
5. Must be in good health as attested by medical certificate
6. Must not have criminal/administrative cases
7. Must be admitted to a Higher Education Institutions (HEI) where the applicant wishes to pursue graduate studies
(for full time scholarship) on full-time basis or must be currently enrolled full-time in the HEI where the applicant
wishes to complete his/her graduate studies (for lateral scholarships)
8. Must not have any ongoing scholarship

Stand-Alone Sandwich Program:

1. Must have a Doctoral Degree in relevant disciplines
2. Must be a Filipino citizen
3. Must be in good health as attested by medical certificate
4. Must not be more than 50 years old
5. Must have have a track record of relevant research experience
6. Must be accepted in the host institution

Form 1 Version 11-2021-A

 Republic of the Philippines
Office of the President
Philippine Space Agency

Checklist of requirements (for staff use only)

Duly accomplished PhilSA Scholarship Program Application Form (Form 1)

Updated Curriculum Vitae

Photocopy of birth certificate

Certified True Copy of Grades/Transcript of Records

Certified True Copy of Diploma/Certificate of Graduation

Certificate of No Pending Administrative Case

Certificate of No Pending Service Obligation

Recommendation letters from 3 academic professors or supervisors (Form 2)

Medical certificate

Research and Career Plans (Form 3)

Duly accomplished Proposed Budget Form (Form 4)

One passport size photo

Valid NBI Clearance

Proof of acceptance in the University or host institution

Form 1 Version 11-2021-A

 Republic of the Philippines
Office of the President
Philippine Space Agency

FORM 1 SCHOLARSHIP PROGRAM APPLICATION FORM

I. PERSONAL INFORMATION

a. NAME

__________________________________________________________________________________________
Last Name Given Name Middle Name

b. PERMANENT ADDRESS

__________________________________________________________________________________________
House No. Street Barangay City/Municipality

__________________________________________________________________________________________
Zip Code Province Region

c. CONTACT INFORMATION

Current Mailing Address: ______________________________________________________________________

Telephone No. _______________________ Mobile No. ____________________________________

Fax No. ____________________________ Email: _______________________________________

d. CIVIL STATUS

Single Married Separated Divorced Widowed

e. DATE OF BIRTH AGE SEX

___________________________________ _____________ __________

Month Date Year

f. CITIZENSHIP COUNTRY OF ORIGIN

__________________________________ __________________________________

g. FAMILY INFORMATION

__________________________________ __________________________________
Mother’s Name Father’s Name

__________________________________ ________________
Name of Spouse No. of Dependents

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 Republic of the Philippines
Office of the President
Philippine Space Agency

(Use additional sheet if necessary)

Name of Dependent Birthday Relation to Applicant
(MM/DD/YYYY)

h. EMERGENCY CONTACT INFORMATION

__________________________________ __________________________________
Emergency contact person Relationship

__________________________________________________________________________________________
Complete Address

_____________________________________ ___________________________________
Contact Number Email address

II. EMPLOYMENT INFORMATION

a. CURRENT EMPLOYMENT STATUS

Self-employed Employed Full-Time Employed Part-Time Unemployed

b. CURRENTLY EMPLOYED APPLICANTS

(FULL TIME/PART TIME)

____________________________ __________________________________________________________
Position Company Name

__________________________________________________________________________________________
Office Address

____________________ _________________________ ________________________________

Length of Service Company Phone Number Company Email

c. SELF-EMPLOYED APPLICANTS

__________________________________________________________________________________________
Company Name

__________________________________________________________________________________________
Company Address

_______________________________ _______________________________
Company Email Company Website

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 Republic of the Philippines
Office of the President
Philippine Space Agency

_______________________________ _______________________________
Company Phone No. Years of Operation

d. EMPLOYMENT HISTORY
(Use additional sheet if necessary)

Period (MM/YYYY) Full Time (F) or Name of Employer Title/Position

Part Time (P)
From To

III. SCHOLARSHIP DATA

a. For New Applicants

__________________________________________________________________________________________
University applied to/intend to enroll

__________________________________________________________________________________________
Course/Degree Program

b. For Lateral Applicants

__________________________________________________________________________________________
University enrolled in

__________________________________________________________________________________________
Course/Degree Program

_____________________________ _____________________________________
No. of Units Earned No. of Remaining Units/Semesters

c. For Stand-alone Sandwich Program Applicants

__________________________________________________________________________________________
University enrolled in

__________________________________________________________________________________________
Degree earned/University where you earned your degree

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 Republic of the Philippines
Office of the President
Philippine Space Agency

__________________________________________________________________________________________
University where he/she will conduct the dissertation

__________________________________________________________________________________________
Research/Project Area

IV. ACADEMIC BACKGROUND

a. SECONDARY EDUCATION

_____________________________________________ _______________________________
High school attended Date Started and Graduated
(MM/YYYY - MM/YYYY)

b. TERTIARY EDUCATION
(Use additional sheet if necessary)

Name of Institution Location Degree Received Enrollment

(MM/YYYY)

From To

c. POST-GRADUATE STUDIES
(Use additional sheet if necessary)

Name of Institution Location Degree Received Enrollment

(MM/YYYY)

From To

d. SCHOLASTIC HONORS & AWARDS RECEIVED

(Use additional sheet if necessary)

Title Awarding Institution Date Received

(MM/YYYY)

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 Republic of the Philippines
Office of the President
Philippine Space Agency

e. RECENT SCIENTIFIC PUBLICATIONS (WITHIN THE LAST FIVE YEARS)

(Use additional sheet if necessary)

Title of Paper Title of Publication Date Published

(MM/YYYY)

f. RECENT SCIENTIFIC CONFERENCE PRESENTATIONS (WITHIN THE LAST FIVE YEARS)

(Use additional sheet if necessary)

Title of Paper Name of Conference Date Published

(MM/YYYY)

g. OTHER QUALIFICATIONS (Eligibilities, Certifications, Professional Licences, Membership to Professional

Organizations, etc.)

Form 1 Version 11-2021-A

 Republic of the Philippines
Office of the President
Philippine Space Agency

V. REFERENCES

Name Company/Organization Email Address

VI. APPLICANT’S DECLARATION

I hereby declare that all information I have provided in this application as well as that in other forms and submitted
documents are true and complete in every respect. I understand that falsifying information at any point in the application
process constitutes sufficient grounds in the disqualification of this application. If accepted to the PhilSA AD ASTRA
Scholarships, I solemnly agree to abide by its rules and regulations.

__________________________________ ___________________________
Applicant’s Signature Over Printed Name Date

Form 1 Version 11-2021-A