Scribd
Upload
307 views2 pages

Scholarship Categorization Application Form

PISAY

Uploaded by

Cheryl Mountainclear
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
307 views2 pages

Scholarship Categorization Application Form

PISAY

Uploaded by

Cheryl Mountainclear
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

PHILIPPINE SCIENCE HIGH SCHOOL SYSTEM

Campus: ____________________________

SCHOLARSHIP CATEGORIZATION APPLICATION FORM


(To be filled out by the student and parent/guardian)

A. STUDENT DATA
1.1 Student Name __________________________________________________________________
(Family Name) (Given Name) (Middle Name)

1.2 Home Address _________________________________________________________________


__________________________________________________ Tel. No. ___________________

1.3 What are the sources of income of the household? (please encircle all applicable items)
1 business 6 remittances from abroad
2 practice of profession (e.g. lawyer) 7 commissions
3 farms/haciendas/fishponds 8 dividends/interests/earnings from investments
4 real estate rentals 9 GSIS/SSS pension
5 salaries or wages 10 Others ______________________________

1.4 Home Ownership: (encircle numeric code)

1 Own house (fully paid)


2 Own house (mortgaged): Monthly amortization P__________________
3 Renting: Monthly rental P__________________
4 Neither owned nor rented Name of owner: _________________________________________
Relationship of owner to family _____________________________
Contributions, if any, to house owner P__________________/month

1.5 Which of the following vehicles are owned by/provided for every member of the family?
(Please fill in appropriate answer)

Number of Units Year Acquired/Model Plate No.


a. Car ________________ ________________ ________________
b. Owner-type jeep ________________ ________________ ________________
c. Passenger jeepney ________________ ________________ ________________
1.6 Real Properties Owned

Lot Area/Floor Area Location Estimated Market Value


_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________

PSHS-00-F-REG-10-Ver02-Rev0-02/01/20 Page 1 of 2
S T A T E M E N T S

Statement of the Applicant

I hereby certify that all the data and information which I have furnished are accurate and complete. I
understand that any willful misinformation and/or withholding of information will automatically disqualify me
from receiving the PSHS scholarship. Furthermore, if such misinformation and/or withholding of information
on my part is discovered after the scholarship has been awarded, I will reimburse all the financial benefits
received.

________________________________________
Applicant’s Signature over Printed Name

Statement of the Applicant’s Parent or Guardian

I hereby certify to the veracity and completeness of the information which my son/daughter/dependent
has furnished in this application. I further recognize that in signing this form, I share with my
son/daughter/dependent the responsibility for the veracity and completeness of the information supplied herein.

________________________________________
Parent’s/Guardian’s Signature over Printed Name

A C K N O W L E D G E M E N T

REPUBLIC OF THE PHILIPPINES )


) S.S.

BEFORE ME, a Notary Public for and in the above jurisdiction personally appeared
___________________________________________ this day of _____________________, ___, with
Community Tax Certificate No. _____________________ issued at ________________________, on
_____________________________, known to me to be the same person who executed the foregoing instrument
and acknowledged to me the same is his true act and deed.

IN WITNESS WHEREOF, I have hereunto set my hand and seal on the date and place above stated.

NOTARY PUBLIC

Doc. No. _________________


Page No. _________________
Book No. _________________
Series of _________________

PSHS-00-F-REG-10-Ver02-Rev0-02/01/20 Page 2 of 2

You might also like