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Graduate Scholarship Application Form School Year: _______________ Applicant’s Name: ______________________________________________________________________________ (Legal Name in Birth Certificate) Last

First

Middle

Nickname

School: _______________________________________________________________________________________ (Current/Last Attended)

INSTRUCTIONS: 1.

Parents, guardians or the student, when applicable, should accomplish this form correctly and completely. Kindly put “NA” if the information asked for is not applicable to you. Do not leave any space blank.

2.

The following documents must be submitted together with this accomplished form  Letter of request from parents/guardians justifying the need for scholarship grant  Sketch of your residence showing directions from UA&P and landmarks;  Three 3R size photos of your permanent residence showing major parts of the house (1 photo of complete view of the house, 1 photo of the kitchen, and 1 photo of the dining area).  Clear photocopy of the most recent Income Tax Return (Proof of Income) of each parent indicating the tax withheld on compensation of the previous year.  Original copy of Billing Statement of the last 3 months (phone/water/electric bills/credit cards);  Certification from current employer of annual salaries and benefits of the applicant, applicant’s parents, or siblings who contribute to family income – submitted copy must always be original.  For parents or guardians who are not employed or not filing any taxes, please submit a CERTIFICATE OF NON-FILING OF TAX issued by the BIR Office.

The requirements need to be complete and accurate in order to facilitate the processing of the application. All information shall be considered confidential. Personal Information 1. School last attended___________________________________________________________________________ 2. Home Address: ______________________________________________________________________________ 3. Mobile Phone no. ____________________________ Tel No.: _____________________________ 4. Email Address: _________________________ Sex ____ Birthday : ________________________ 5. For provincial Applicants, where will the student live during his/her studies in UA&P? Dorm / Boarding House With a Relative Own Residence in Manila Others, please specify: ___________________________ 6. In which other universities / foundations / agencies are you applying for a scholarship or financial assistance grant? _____________________________________________________________________________________________ _____________________________________________________________________________________________

Family Background Father

Mother Name Birthdate Deceased (Yes/No)

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Permanent Home Address Zip Code Telephone Number/Fax Number Cellphone Number Email Address Highest Educational Attainment Last School Attended Occupation If self-employed, nature of work Number of Years in Business Amount of Capital Investment Annual Gross Income ( Annual Commissions, Fees, or Allowances ) Annual Net Profit If employed, name of Company/Employer Business Address Position Number of Years employed in the job Annual Gross Income (salary) Annual Additional Income (Allowances, Per Diem, Bonus) If Unemployed: Company last employed Date and Year of last employment Reason(s) for being unemployed

* Please do not leave any item unanswered.

1.

2. 3. 4. 5. 6.

Name(s) of : Children(if parent is answering form) Siblings (if applicant is answering form) Age Civil Status Grade/Year/ Highest Educational Attainment School Still residing with the immediate family?

(Yes /No) 7. If currently enrolled, kindly indicate the amount of tuition fees and the person shouldering the payment (i.e. parent 8. Enrolled under educational plan ___Educational Plan ___Company Benefit ___Others (specify) 9.

10.

11. 12. 13.

If currently availing of ascholarship or financial assistance from other sources, kindly indicate the type and amount. If already employed, or has own business, kindly indicate the position and nature of the business. Name of company / employer. Annual Gross Income Helping with the expenses?

__Yes__No

__Yes__No

__Yes__No

__Yes__No

__Yes__No

14. Indicate other dependents living in the house. (specify) 15. Are there others (relatives/friends) helping in the expenses?

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16. Are any of the family members under a certain petition to migrate abroad? If yes, please indicate who andthe country. Otherwise, does anyone have plans to migrate or work abroad in the next few years? Please indicate who and the country. 17. Amount contributed to educational expenses. 18. Amount contributed to household expenses 19. Number of Helper(s) (salary per helper) 20. Number of Driver(s) (salary per driver)

Assets

A. House and Lot __Single Detached __Owned

__Apartment __Rented

__Condo __Under Mortgage

__Townhouse

1. Location /address

2. Size of lot 3. Number of bedrooms 4. Number of bathrooms 5. Date of acquisition

6. Acquisition cost 7. Fair market value 8. Number of years in residence 9. Amount of Monthly rental. Kindly submit receipts of rental payments for the last three (3) months. 10. Bank or agency where loan was secured. 11. Total amount of mortgage. (Submit copy of receipt of payment.) 12. Amount of Monthly mortgage. Kindly submit receipts of mortgage payment made for the last three (3) months 13. Number of years to pay for mortgage loan

B. Other Properties Residential

Commercial

1. Description

2. Location/Address

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3. Size 4. Date of acquisition 5. Acquired Value 6. Current Market Value 7. Monthly Net Income

C. Cars and Other Motor Vehicles Maker

Model

Year

Acquisition Cost

Payment Terms (please check) __ Fully Paid __ Installment __ Monthly Payment (amount:_________) __ Fully Paid __ Installment __ Monthly Payment (amount__________) __ Fully Paid __ Installment __ Monthly Payment (amount__________)

D. Household Items Indicate number

Date Acquired

Acquisition Cost

Fully Paid? Installment Basis? (indicate number of months / years to pay)

Monthly Payment

TV set (__) Entertainment system / DVD or HD player (__) Ipod / MP3 player (__) Gaming Gadgets: Play Station / Nintendo/ others (__) Personal computer / laptop (__) Refrigerators (__) Freezer (__) Microwave oven (__) Airconditioner (__) Musical Instruments: Kindly specify kind of instrument: (__) Electric / Gas range (__) Washing machine (__) Dryer (__) iPad / Tablet (__) Cellular phone, Smartphone, kindly specify brand and model of phone(s) (__) Landline telephone (__)

Family’s Financial Status A.

Monthly Gross Family Income

1. Total Compensation Income (Father/Mother/Sister/Brother) 2. Income from Business 3. Income from Land Rentals 4. Income from Residence/Building Rentals/Lease 5. Retirement Pension 6. Commissions 7. Support from Relatives 8. Bank Deposits :

Php

a. Savings/Current b. Bank Placements/Investments c. Bonds/Treasury bills d. Foreign Currency Deposit e. Stocks

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9. Kindly indicate bank, branch and balance of account/s as of current month and year

10. Others (Specify)

Total B.

Php

Monthly Gross Family Expenses

1. House rental 2. Car loan amortization 3. Other loan amortizations (specify) 4. School tuition 5. School bus fares 6. Transportation and gasoline 7. Educational plan premiums 8. Insurance policy premiums 9. SSS / GSIS / PAG-IBIG 10. Withholding tax 11. School and office uniforms and clothing 12. Electricity 13. Telephone and mobile phone 14. Water 15. Cooking gas 16. Helper’s salary 17. Driver’s salary 18. Medicines 19. Cable Subscription 20. Internet Subscription 21. Health insurance premiums 22. Doctor’s fees and consultation 23. Hospitalization 24. Groceries 25. Other food expenses 26. Entertainment and recreation 27. Other expenses, please specify:

Total

Php

* If the amount of total expenses is higher than your indicated income, kindly justify below on how the deficit is covered.

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

C E R T I F I C A T I O N This is to certify that all the information given is accurate. We are aware that any false data will be a ground for disapproval or cancellation of a grant. We also authorize the school in charge to verify the information given.

____________________________

___________________________

Signature over printed name of Father

Signature over Printed name of Mother

________________________________ Signature over printed name of applicant

_______________________________ Date Signed

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