TO BE FILLED OUT BY AUTHORIZED

PERSONNEL:
APPLICATION
CONTROL NO.
DATE RECEIVED
RECEIVED BY
CITY GOVERNMENT OF VALENZUELA REMARKS:
DR. PIO VALENZUELA SCHOLARSHIP PROGRAM
2nd Flr., Student Center Bldg., Pamantasan ng Lungsod ng Valenzuela, Maysan, Valenzuela City

APPLICATION FORM
TO THE STUDENT/APPLICANT:
Carefully read the QUALIFICATION AND REQUIREMENTS before filling out this application form.

Print legibly all information required. Place X marks in appropriate boxes. Indicate N/A if the item is not
applicable. Only qualified applicants who completed the requirements will be processed.

1. NAME OF APPLICANT (As it appears on the Birth Certificate)

LAST NAME NAME EXTN.

FIRST NAME Attach a recent 2”x2” photograph

(White background)
MIDDLE NAME
Insert a computer-generated format
2. SEX MALE FEMALE 3. PLACE OF BIRTH name using this format:
4. DATE OF BIRTH (mm-dd-yyyy) - - 5. CITIZENSHIP LAST NAME, FIRST NAME MIDDLE INITIAL

6. RELIGION 7. AGE

8. ARE YOU A REGISTERED VOTER OF VALENZUELA CITY? YES NO

9. CURRENT ADDRESS
House/Flr./Lot/Blk. # Street/Subdivision/Village Barangay City ZIP Code

Is this also your permanent address? YES NO

10. PERMANENT
ADDRESS House/Flr./Lot/Blk. # Street/Subdivision/Village Barangay City ZIP Code

11. ACTIVE EMAIL ADDRESS 12. ACTIVE MOBILE NO.

13. SOCIAL MEDIA URL (FACEBOOK) 14. TELEPHONE NO.

15. SENIOR HIGH SCHOOL (where you completed/are completing SHS level education) (DO NOT ABBREVIATE)

NAME OF SCHOOL

SCHOOL ADDRESS

TRACK/STRAND YEAR OF COMPLETION

16. ENROLLMENT HISTORY

GENERAL
ADDRESS HONORS /
GRADE LEVEL NAME OF SCHOOL WEIGHTED
(CITY, TOWN/PROVINCE) RANK
AVERAGE
GRADE 11

GRADE 10

GRADE 9

GRADE 8

GRADE 7

17. HAVE YOU APPLIED/PLANNING TO APPLY TO OTHER SCHOLARSHIP PROGRAMS? YES NO

IF YES, PLEASE SPECIFY:

1. _____________________________________________________ 2. _________________________________________________________

18. WHAT SCHOOL/UNIVERSITY HAVE YOU APPLIED/PLANNING TO APPLY FOR COLLEGE?

FIRST CHOICE PREFERRED UNDERGRADUATE PROGRAM

SECOND CHOICE PREFERRED UNDERGRADUATE PROGRAM

 19. SOCIO-ECONOMIC DATA. Furnish all the required information on each family member listed. Write DECEASED after name of deceased family
member/s.
NAME EDUCATIONAL MONTHLY CONTACT
AGE OCCUPATION EMPLOYER
(LN, FN, MI) ATTAINMENT INCOME NO.
MOTHER

FATHER

LEGAL GUARDIAN

A. Currently living with PARENT/S RELATIVE/S GUARDIAN/S If others, please specify: ______________________

C. Are you/your family is a beneficiary of any government assistance program?

B. How many years are you living with them? (refer
If yes, please specify. If no, please write N/A.
to 19-A)
_____________________________________________ ____________________________________________________________________
D. Does your parent/s work abroad? If yes, state the
Years work in abroad: _________________________________________________
country:
_____________________________________________ Nature of Work: _________________________________________________________

E. SIBLING/S INFORMATION. Arrange in order of eldest to youngest. Do not include yourself.

NAME EDUCATIONAL MONTHLY CIVIL

AGE OCCUPATION EMPLOYER
(LN, FN, MI) ATTAINMENT INCOME STATUS

F. Does any of your siblings have been a Dr. Pio Valenzuela Scholarship grantee? If yes, please specify the name and Batch number. If
none, please write N/A. _______________________________________________________________________________________________

I affirm that: I certify that:

(1) I have read all the information regarding the qualification and (1) The information which my son/daughter/dependent has furnished in
requirements of Dr. Pio Valenzuela Scholarship Program.
this application form is true, complete, and accurate.
(2) All the information supplied in this application form are true, complete,
and accurate. (2) I read and understand the qualification and requirements of Dr. Pio
(3) I will pass all the necessary documents and requirements appertaining Valenzuela Scholarship Program.
to my application to Dr. Pio Valenzuela Scholarship Program. (3) I will abide by the rules and policies of Dr. Pio Valenzuela Scholarship
(4) I will abide by the rules and policies of Dr. Pio Valenzuela Scholarship Program.
Program.
I recognize that in signing this application form, I share with my
I am aware that any or all the information furnished in this application may
son/daughter/dependent the responsibility for the veracity and
be checked against the original documents and that withholding
information or given false information will disqualify me from applying/will completeness of the information supplied therein.
be a basis of forfeiture, if evaluated/granted. I also understand that no
results for my application may be released until all requirements are
satisfied.

SIGNATURE OF APPLICANT SIGNATURE OF PARENT/GUARDIAN

_________________________________________ _________________________________________
DATE DATE

The Dr. Pio Valenzuela Scholarship Program recognize their responsibilities under the Republic Act No. 10173 (Act), also known as the Data Privacy Act
of 2012, with respect to the data they collect, record, organize, update, use, consolidate or destruct from the applicants. The personal data obtained from
this form is entered and stored within the Program’s authorized information and communications system and will only be accessed by the authorized
personnel. The Dr. Pio Valenzuela Scholarship Program have instituted appropriate organizational, technical and physical security measures to ensure
the protection of the applicant’s personal data.