PSP Form No.
1
REPUBLIC OF THE PHILIPPINES
PROVINCE OF PANGASINAN
Lingayen
PSP ACADEMIC SCHOLARSHIP APPLICATION FORM
I wish to apply for scholarship assistance under the Program (please check):
Academic Automatic
Sports Culture (NCIP, FPMA).
Arts
I wish to enroll at _____________________________________________________________________________________
(Name of school and address)
for the course __________________________________________________________ effective Academic Year 2020-2021.
In support to my application, attached are the following documents:
1. Senior High School Report Card (certified photocopy by the School Principal or Registrar)
2. Medical Certificate from a government physician (original copy)
3. Duplicate copy of Income Tax Return (ITR) of Parent/Guardian or Certificate of Tax Exemption from the Bureau of
Internal Revenue (BIR) if parent/guardian is exempted from tax (original copy)
4. Certificate of Scholarship Eligibility (PSP Form No. 2)
5. Individual Information Sheet (PSP Form No. 3) with recent picture. (Taken within the last six (6) Months)
I hereby authorize the Provincial Scholarship Program Management, Evaluation and Excellence Committee (PSPMEEC)
or its duly authorized representative, to investigate all facts concerning my skills, habits, character, background and such other
information pertinent to my qualifications.
I understand that any misrepresentation, falsification or any omission of such fact, of whatever nature, required by this
application shall be considered a sufficient cause for denial of my application or termination of my scholarship privileges if
already granted.
If accepted, I promise to abide by the rules and regulations, as embodied in the provisions of the Guidelines for PSP for
Highly Competent College Students, which I have read and fully understood.
___________________________________________
(Applicant’s Signature over Printed Name)
___________________________________________
(Name and Address of School Graduated)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
PSP Form No. 2
CERTIFICATE OF SCHOLARSHIP ELIGIBILITY BY THE HIGH SCHOOL PRINCIPAL
This is to certify that ________________________________________________________ is a candidate for graduation
(Name of applicant)
from __________________________________________________________________ on ________________________________
(Name of school and address) (Date of graduation)
under the __________________________________________________________ and meets all the requirements for graduation.
(Academic Track/ Strand)
This is to certify further that he/she is of good moral character. He/ She is a recipient of the following academic and
non-academic awards and citations:
Date Title of Competition Award Received Level
(mm/dd/yy) (Champion, Runner-Up etc.) (Municipal, Provincial, National, etc.)
1
2
3
4
5
TOTAL NO. OF GRADUATING SENIOR STUDENTS: _________
ATTESTED:
_________________________________
(Signature over Printed Name)
School Head of Applicant
___________________
Date
Note: PSP Academic Scholarship Application Form may be reproduced. Page 1 of 3 (January 6, 2020)
PSP Form No. 3
INDIVIDUAL INFORMATION RECORD
Name: _______________________________________________Age: ______________Gender: ______
Directions: Give what is being called for as accurately and honestly as you can. Any misrepresentation may disqualify you for the
scholarship. PART III should be accomplished with the help of your parents or guardians.
PART I
1. Date of Birth (mm/dd/year)_________________________ Place of Birth__________________________________________
2. Present Address ________________________________________________________________________________________
3. Contact Number/s: _____________________________________________________________________________________
4. No. of years of stay in the present address___________________________________________________________________
PART II
1. Name and address of secondary school _____________________________________________________________________
______________________________________________________________________________________________________
2. Classification of High School Curriculum, /___/General, /____/Vocational, /____/ Special Program (Pls. specify) ___________
3. Date of Graduation ______________________________________________________________________________________
4. Academic Honors Received _______________________________________________________________________________
5. Non-Academic Honors Received ___________________________________________________________________________
6. Special Talents and Skills _________________________________________________________________________________
PART III
1. Father’s Name _____________________________________ Occupation __________________________________________
Gross Income per month _________________________________________________________________________________
Amount of Income Tax paid for previous year ________________________________________________________________
2. Mother’s Name____________________________________ Occupation __________________________________________
Gross Income per month _________________________________________________________________________________
Amount of Income Tax paid for previous year ________________________________________________________________
3. Guardian’s Name (if applicable)__________________________________ Occupation ________________________________
Gross Income per month _________________________________________________________________________________
Amount of Income Tax paid for previous year ________________________________________________________________
4. What do you like to be someday? _________________________________________________________________________
What does your father like you to be? ______________________________________________________________________
What does your mother like you to be? _____________________________________________________________________
What do your teachers like you to be? ______________________________________________________________________
What do your friends like you to be? _______________________________________________________________________
5. How many brothers and sisters do you have? ________________________________________________________________
How many are studying? _________________________________________________________________________________
Elementary: _________Junior High School: ___________Senior High School ___________College: ______________________
6. What other means of income does your family have aside from those mentioned in questions 1 and 2.
Please list them below:
Other Sources of Income Monthly Income
________________________ _______________________
________________________ _______________________
7. In at least 50 words, state your reason for applying for this college scholarship.
________________________________________________________________________________________________________
_______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
I HEREBY CERTIFY that the answers ATTESTED:
to the foregoing are true and correct.
__________________________________________ _____________________________________________
(Applicant’s signature above printed name) (Parent’s/Guardian’s signature above printed name)
_______________ _______________
(Date) (Date)
Note: PSP Academic Scholarship Application Form may be reproduced. Page 2 of 3 (January 6, 2020)
Note: PSP Academic Scholarship Application Form may be reproduced. Page 3 of 3 (January 6, 2020)
