Republic of the Philippines

PROVINCE OF NORTHERN SAMAR

1/F New Provincial Capitol
--- Catarman ---

NORTEHANON: MARIG-ON, MAINUSWAGON, MALIPAYON

APPLICATION FORM
ISKOLAR NG PROBINSYA 2x2
ID PHOTO

New Renewal School Year 2021- 2022 1st Semester 2nd Semester

Name :____________________________________________________________ Sex:______________ Age:_________

(Last Name) (Given Name) (Middle Name)
Date of Birth :_________________________ Citizenship :______________________ Civil Status:_________________
Mobile No. :_________________________________Email Address:__________________________________________
House No./ Street :__________ Brgy :_____________________ Municipality:____________________, Northern Samar
Course:__________________________________________Year Level (Present) : _______________________________
School Name :__________________________________________________ Student ID #: ________________________

NAME OF PARENTS OCCUPATION EMPLOYER ANNUAL INCOME

Father:
Mother:

____________________________ _______________________
Applicant’s Signature Date

ATTACHMENTS: (FOR NEW APPLICANTS)

CERTIFIED TRUE COPY OF CERTIFICATE OF REGISTRATION (COR) of the current

semester, to be obtained from the School Registrar/ Admission Officer (2 copies)

CERTIFICATE OF RESIDENCY AND CERTIFICATE OF GOOD MORAL CHARACTER from

the Office of the Mayor or Barangay Captain (2 copies)

CERTIFICATE OF INDIGENCY from the Municipal Social Welfare Development Office or

Provincial Social Welfare Development Office. (2 copies)
or INCOME TAX RETURN (for applicants whose parents are employed) (1 copy).

ATTACHMENTS: (FOR RENEWAL)

CERTIFIED TRUE COPY OF REPORT OF GRADES of the previous semester, to be obtained from
the School Registrar/ Admission Officer (2 copies) FIRST SEMESTER 2021-2022 WITH CERTIFIED
TRUE COPY.

CERTIFIED TRUE COPY OF CERTIFICATE OF REGISTRATION (COR) of the current

semester, to be obtained from the School Registrar/ Admission Officer. (2 copies) COR SECOND
SEMESTER 2021-2022 AUTHENTICATED WITH CERTIFIED TRUE COPY

Received by:_____________________________ Date: ________________________

CERTIFIED AS TO THE COMPLETENESS OF REQUIREMENTS

________________________________________ ____________________________
In-charge Date