‘18123, 10:52 PM ‘Application Form REPUBLIC OF THE PHILIPPINES. PROVINCE OF LAGUNA OFFICE OF THE GOVERNOR Provincial Capitol Compound , Santa Cuz, Laguna APPLICATION FORM. ‘SCHOLARSHIP PROGRAM OF LAGUNA IST SEM. A.Y. 2022-2023 "TORE FILLED UPRY THE studa ‘A. PERSONAL INFORMATION: Handwritten (print / Typewritten Slot No, 2021-05672 ‘Nome of Student LIBRADA, SHENNA MAB, M. (Somamey (Given Name) wD Age 2 Sex Female Status SINGLE Religion ROMAN CATHOLIC Date of Binh 2002-05-21 Place of Bit BITIN, BAY, LAGUNA. Residential Address in Laguna 0297 M.AQUINO ST Province LAGUNA ‘Muanicipalsy BAY ‘Barangay BION Contact No, 09569501211 mail Address. shomamoy@igmailcom [Name of Father FERDINAND LIBRADA, ‘Occupation SECURITY GUARD Contact No, DSERHT [Name of Mother CATHERINE LIBRADA ‘Occupation NONE ‘Contact No, 09263684851 [Name of Guardian PRESENTACION MALAGNO Relat ‘Annual Family Gross Income 120000, GRANDPARENT Contact No, 09172586028 Sel Gade Ades of Soa Year Graded Renews) arn eueentary scuoon, — “SHITNt Ste LAGUNA Sole . BITIN INTEGRATED . Secondary yaBitININTEGRATED arn nav, LAGUNA, 2ois TIRSTASIA INSTITUTE OF 5 Senior tig — trcHINOLoY AND TANAUAN CTY, nono HUMANITIES TAN B. ADDITIONAL INFORMATION (Course Already Enrolled BACHELOR OF SCIENCE IN ACCOUNTANCY ool (CARD MRI DEVELOPMENT INSTITUTE ‘Address of School _TRANCA, BAY, LAGUNA, Number of Units Year Level 3 Gradating?__NO [Expected Vear of Graduation Semester NK po1ss7021 ‘Are you areviient f ay other government funded financial assistance/scholarship program? "No ‘Yes (Please specify: ‘Are tere any member ofthe family who is currently “Iskolar ng Laguna”? x No Yes Thereby cry that Ihave read the terms and conditions governing grant as provided for by the Scholarship Program of the Provineial Government of Laguna and is implementing rues and regulations and hereby pledge stil observance end ‘compliance therewith. Further, by eifixing my signature, AM CERTIFYING THAT THE ABOVE INFORMATION IS TRUE ‘AND CORRECT and also giving my consent fo process my personal data based on the Data Protection Policy (Gagua gov phiopa). With My Consent (CATHERINE LIBRADA LIBRADA, SHENNA MAEM. ate over printed name of Parent Guardian Signatre over printed name of Stade