CHED-Scholarship Application Form ANNEX "A"
2019 version (NOT FOR SALE)
Office of the President of the Philippines
COMMISSION ON HIGHER EDUCATION
REGIONAL OFFICE VIII 2X2
CHED SCHOLARSHIP PROGRAM (CSP) ID PICTURE
APPLICATION FORM
Academic Year 2019-2020
Instructions: Read General and Documentary Requirements. Fill in all the information. Do not leave an item blank. If item is not applicable, indicate "N/A"
Application period: March 1 to May 31 of the current academic year
ELIGIBILITY REQUIREMENTS per CMO____s. 2019
1. Filipino citizen DOCUMENTARY REQUIREMENTS per CMO___s., 2019
2. Graduating high school students/High School graduate 1. Certified True Copy of Birth Certificate
3. General Weighted Average (GWA) of at least 90% or above Academic Requirements - any one of the following:
4. Combined annual gross income of parents/guardian not to exceed Four Hundred Thousand () 1. High School report card for incoming freshmen students eligible for college
Pesos (Php400,000) or solo parent/guardian whose annual gross income does not exceed the
() 2. Duly certified true copy of grades for Grade 11 and 1st semester of Grade 12 for graduating high
said amount
school students
In highly exceptional cases where income exceeds Php400,000.00 an applicant must present Income Requirements - any of the following:
a written certification or medical findings of illness of a family member, or school
certifications of two or more dependents enrolled in college: () 1. Latest ITR of parents or guardian if employed
5. Avail of only one government funded financial assistance program
() 2. Certificate of Tax Exemption from the BIR
() 3. Certificate of Indigence from their Barangay
NOTE: () 4. Certificate/Case Study from DSWD
Beneficiaries of free higher education under RA 10931 can only receive stipend unde this () 5. Latest copy of contract or proof of income for children of Overseas Filipino Workers (OFW) and
program seafarers.
PERSONAL INFORMATION
1. Name
(Last Name) (First Name) (Middle Name) (Extensison Name) i.e.Jr., III
2. Date of Birth (mm/dd/yy) 9. Permanent Address
3. Place of Birth (Street/Brgy., Town/City,
Province)
4. Sex Male Female 10. Zip Code 11. District
5. Civil Status Single Widowed 12. Name of School Last Attended
Married Separated 13. School Address
Annulled Others
6. Citizenship
7. Mobile Number 15. Learner Reference Number (LRN)
8. E-mail Address 17. Type of Disability
14. School Sector: ( ) Public ( ) Private 18. IP affiliation (if applicable)
16. Highest Attained Grade (Year Level):
FAMILY BACKGROUND
19. Full Name (including middle Father: ( ) Living ( ) Deceased Mother ( ) Living ( ) Deceased Legal Guardian
name)
20. Address
21. Contact Number
22. Occupation
23. Name of Employer
24. Employer Address
25. Total Parents Annual Gross
Income
26. Number of Siblings
27. School Intended to enroll or enrolled in:
28. School Address:
29. Type of School: ( ) Public ( ) Private
30. Degree Program:
Type Grantee Institution/Agency
31. Are you enjoying other sources of educational/financial assistance? ( ) Yes or ( ) No if yes, Please specify 1. _________ ______________
2. _________ ______________
I hereby certify that foregoing statements are true and correct. Any misinformation or witholding of information will automatically disqualify me from the CHED Scholarship Program. I am
willing to refund the financial benefits received if such information is discovered after acceptance of the award.
I hereby express my consent for the Commission on Higher Education to collect, record, organize, update or modify, retrieve, consult use consolidate, block, erase or destruct my personal
data as part of my information.
I hereby affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my personal data and be indemnified in case of damages pursuant to the provisions of
the Republic Act No. 10173 of the Philippines, Data Privacy Act of 2012 and its corresponding implementing Rules and Regulations.
(Signature over Printed Name of Applicant) Date Accomplished
Note: Fully accomplished form to be submitted to the CHEDRO
DO NOT FILL-OUT THIS PORTION (FOR CHED USE ONLY)
Belongs to: (any of the following groups) Documents Attached:
dependent of solo parent 1. Academic
senior citizens ( ) Report Card ( ) Copy of Grades: Grade 11 or 1st semester of Grade 12
persons with disabilities 2. Financial
indigenous and ethnic peoples ( ) ITR ( ) Tax Exemption ( ) Certificate of indigency
DSWD's Pantawid Pamilyang Pilipino Program (4Ps) ( ) Case Study DSWD ( ) OFW Contract
3. Others
( ) Solo Parent ( ) Senior Citizen ( ) IPs ( ) PWD ( ) 4Ps
School intended to enroll in
School Address
Type of School ( ) Public ( ) Private
Course ( ) Priority ( ) Non-Priority
Evaluated/Processed by:
CHED StuFAP Coordinator Date
