RIZAL PROVINCIAL GOVERNMENT

“ISKOLAR NI GOB” APPLICATION FORM

PASTE RECENT 2X2
PHOTO with name
(NOT FOR SALE) This form can be reproduced
Date of Exam: Deadline of Submission:

REMINDER:
Please print all the information and avoid erasures. Submit (1) copy of this form. ONLY APPLICATION
ACCOMPLISHED CORRECTLY AND COMPLETELY WILL BE PROCESSED.

PERSONAL DATA
NAME: (LAST) ANOTADO (FIRST) AJ (MIDDLE) G AV IOL A
BIRTHDAY: 0 3 -3 1 -2 0 0 3 AGE: 2 0 GENDER: 2 0 BIRTHPLACE: C AL B AY OG S AM AR RELIGION: C H R IS TIAN
ADDRESS: No./St. S ITIO C AB ADING Brgy: S AN J OS E (P OB ) Municipality: ANTIP OL O

Number of years residing in Rizal Province : 17 Tel. No. /Cellphone No.: 09938670276
Email Address: e y je y s h ig a @ g m a il.c o m Social Media Accounts: F AC E B OOK : AJ G AV IOL A ANOTADO
FAMILY BACKGROUND
FATHER/GUARDIAN MOTHER/GUARDIAN
Name B E NJ AM IN F . ANOTADO J R . AR L E NE G . ANOTADO
Highest Educational Attainment E L E M E NTAR Y C OL L E G E U NDE R G R AD
Contact Number 09062751341 N /A
Occupation F AB R IC ATOR H OU S E W IF E
Employer A- POWER ELECTRICAL SERVICES N /A
Monthly Family Income LESS TH AN 1 5 ,0 0 0 N /A
Annual Family Income (LATEST) Other Source of
1 2 0 ,0 0 0 Income
N /A
No. of Children/Dependent/s in 3 Their Ages
the Family
20,22,25

ANY COLLEGE SCHOLARSHIP GRANT BEING ENJOYED BY SIBLING / RELATIVE

NAME RELATIONSHIP PROGRAM/SPONSOR YEAR/ COVERAGE AMOUNT OF GRANT

N /A N /A N /A N /A N /A
N /A N /A N /A N /A N /A
DECLARANT’S RELATIVE/S WORKING IN THE GOVERNMENT
NAME RELATIONSHIP POSITION OFFICE ADDRESS
N /A N /A N /A N /A N /A
N /A N /A N /A N /A N /A
ACADEMIC BACKGROUND
NAME OF SCHOOL ADDRESS YEAR
ELEMENTARY M AY AM OT ELEM EN TARY SCH OOL B RG Y . M AY AM OT, A.C 2 0 1 1 -2 0 1 6
JUNIOR HIGH SCHOOL M AY AM OT N ATION AL H IG H SCH OOL B RG Y . M AY AM OT, A.C 2 0 1 6 -2 0 2 0
SENIOR HIGH SCHOOL M AX IM O L. G ATLAB AY AN M N H S SITIO PAEN AAN 2 0 2 1 -2 0 2 3
INTENDED DEGREE PROGRAM / COLLEGES & UNIVERSITIES
Name three (3) degree courses/program of study you wish to pursue
1stChoice F IN E ARTS 2nd Choice ARCH ITECTU RE 3rd Choice IN TERIOR D ESIG N
Name three (3) schools where you wish to study, Schools must be located in Rizal Province and Metro Manila Areas. The campuses of University of the
Philippines (UP) located in Los Banos & Baguio are considered
1stChoice U P 2nd Choice PU P 3rd Choice M LQ U

ISKOLAR NI GOB program

TEST PERMIT
ROOM No._____ SEAT No. ______
AJ G . AN OTAD O M
NAME: ____________________________________ GENDER:_______
SCHOOL:____________________________________________________
PASTE RECENT 2X2
PHOTO with name
This is to certify that the above applicant is qualified to take the Written Qualifying Examination
on _________________6:30 a.m to be held at ______________________________

_________________________________
Test Administration Committee
BASIC DOCUMENTARY REQUIREMENTS:
1. Accomplished “ISKOLAR NI GOB” Program Application Form
2. Grade Requirement
Certified true copy of Grade 12 Report Card duly signed by the Registrar & Principal with grade requirement of at least 85%
in EVERY SUBJECT taken in the 1st Semester.
3. Photocopy of NSO (PSA) Birth Certificate
4. Photocopy of Voter’s ID or Voter’s Certificate of Registration issued by COMELEC (Applicant/Parents/Guardian)
5. (2) pcs. recent 2x2 photo with name

CERTIFICATE OF GOOD MORAL CHARACTER

This is to certify that __________________________________ has consistently maintained good moral character.
There having no disciplinary action taken against him/her as to date.

__________________________________________
Printed Name & Signature of the Guidance Counselor School Seal

BARANGAY CERTIFICATE OF RESIDENCY

This is to certify that __________________________________ is a resident of
_____________________________Province of Rizal, since _________. Further, this is to certify that __________________
has a good moral character; he/she has no derogatory record in the community.
This certification is issued upon the request of said__________ in connection with his/her scholarship application in
“Iskolar ni Gob” Program.

_______________________________________
Printed Name & Signature of the Barangay Captain
Barangay Seal

SIGNED DECLARATION BY THE APPLICANT & PARENTS / GUARDIAN

We hereby certify the truthfulness and completeness of the information we have stated above. Any
misinformation/misrepresentation or withholding of information will automatically disqualify and/or terminate the scholarship grant
of the undersigned applicant from the “Iskolar ni Gob” Program. In connection with this, I/We hereby authorize the Rizal Provincial
Government to conduct background check on the family finances and to visit our residence.

__________________ _________________________ _________________________

Applicant’s Signature Father’s/Guardian’s Signature Mother’s/Guardian’s Signature

_______________________
Administering Officer

REMINDER:
 Please wear appropriate attire on the Examination Day
 Please bring the following on the Examination Day
a. This Permit
b. Your Senior High School I.D.
c. Black or Blue Ballpens (pencils are not allowed)
d. Packed lunch, drinking water, juices, sandwiches and candies
NO PERMIT, NO EXAM POLICY