SIKAP PT: FORM A

CERTIFICATE OF ELIGIBILITY AND UNDERTAKING

Application for the Part-Time Study under SIKAP Grant

I, <<FullName>>, Filipino, <<Age>>, with permanent address at <<Complete Address>>,

after being sworn in accordance with law, hereby depose and state that:

1. I am applying for the Part-Time Study under the Scholarships for Staff and
Instructors’ Knowledge Advancement Program (SIKAP) Grant;
2. I am employed as a Teaching or Non-Teaching Personnel in a Higher Education
Institution (HEI), at the time of application; (accomplish table, as applicable)

Type Institution/s of Rank1 Employment Length of

(Check all that apply) Employment Status2 Service
(e.g. __ Years and __
Months)

❏ Employed 1.

Choose one:
❏ Single
Employment 2. (Add more rows if
❏ Multiple necessary)
Employment

❏ Self-
Employed

❏ Others

3. I am admitted or will enroll in an eligible graduate degree program offered by

designated Delivering Higher Education Institutions (DHEIs) which is/are:

(check applicable box)

☐ Autonomous/Deregulated Institutions;
☐ State Universities and Colleges (SUC) designated as Level III and above;
☐ Center of Excellence (COE) or Center of Development (COD);
☐ A program accredited as or whose equivalent undergraduate program is a
accredited as Program Level III or above; OR
☐ Mindanao State University (MSU) and its constituent units or the University of
the Philippines (UP) and its constituent units.

4. If my employment status is covered under Section 2.1.2.1, 2.1.2.2, and 2.1.2.3 of

CMO No. 28, s. 2021, I shall submit the proposed thesis/dissertation that is aligned
with the research and development agenda of either the SHEI and/or DHEI as
attested by the HEI President or its equivalent;
1 Professor, Associate Professor, Instructor, Lecturer, Guest Lecturer, Dean, Director, Registrar etc
2 Regular / Plantilla, Probationary / Temporary, Contractual / Contract of Service, Separated /
Unemployed
SIKAP PT: FORM A

5. I shall secure a permit to study from the SHEI President or its equivalent and duly
endorsed by the Faculty and Staff Development Committee or its equivalent;
6. I am physically fit and mentally prepared to undertake and complete graduate work
as supported by a medical certificate;
7. If my employment status is covered under Section 2.1.2.1 and 2.1.2.2 of CMO No.
28, s. 2021 (Full-time Faculty or HEI Personnel with plantilla/tenured or
temporary/probationary appointments), I am of age that is not more than 50 years old
to allow me sufficient time to render and complete return service obligation after
obtaining my graduate degree and impart my acquired degree to the higher
education sector;
8. I shall disclose to the Commission if I have a relationship, up to the fourth (4th)
degree of consanguinity or affinity, with any CHED employee in the CHED Regional
Office (CHED RO) where the application is being processed3;
9. I am not holding a degree in the same degree level being applied for (i.e. applicants
applying for scholarship to pursue a doctorate degree, must not already possess a
doctorate degree);
10. I am not enrolled in more than one graduate program;
11. IF already admitted to a graduate program, I do not have failing grades, dropped
courses, have not shifted/changed the program of study, or on extension or beyond
the regular study plan;
12. I am cognizant, willing, and accepting of this commitment, and the various terms and
conditions of this grant as stipulated in the CMO No. 28, s. 2021 and all relevant
CMOs and shall comply with the same, and
13. I fully understand the consequences of not giving correct and truthful data and I am
aware that non-disclosure of material information as required by CMO No. 28, s.
2021 will put me under the pain of perjury by executing this document.

WHEREFORE, in order to attest to the truth of the foregoing, I hereby affix my signature to
this Certification this ___ day of (Month), 2022 in (City/Municipality).

___________________________
Signature over printed name

SUBSCRIBED AND SWORN to before me, this __ day of ___ 2022 at _______, Philippines.

<<NOTARY>>

3 Based on the Administrative Code of 1987, Executive Order No. 292 and SC Memorandum Circular No. 21, s.
2004