... and 6) Letter of intent address to Donor/ADSA. Please submit all signed documents in a single .pdf file to mparciga@
University of the Philippines College of Engineering Associate Dean for Student Affairs Office Rm. 209, Melchor Hall, Diliman, Quezon City 1101 Tel/Fax: +632 981 8500 ext 3152
ID PHOTO Undergraduate Scholarships and Study Grants
APPLICATION FORM INSTRUCTIONS: Accomplish this form and submit to the Office of the Associate Dean for Student Affairs, UP College of Engineering. Attach with this form the following: 1) a letter of endorsement from your department chairperson/institute director; 2) an SDC clearance; 3) a copy of recent Form5 with ID; 4) a copy of parents ITR; 5) TCG; and 6) Letter of intent address to Donor/ADSA. Please submit all signed documents in a single .pdf file to
[email protected]
Applicant Name: _______________________________________ Student Number: ______________ Date and Place of Birth: _________________________ Citizenship: ___________________ Current Address: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Home Address: ______________________________________________________________ _____________________________________________________________ _____________________________________________________________ Landline/Mobile/E-mail: ________________________________________________________ Parent/Guardian Name: ____________________________________ Contact No./E-mail: _________________ Address: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 1. Name of Scholarship(s)/Study Grant(s) Applied for and Desired Semester/Year of Award:
___________________________________________________________________ (May be left blank. The committee will endorse/nominate you for the first available scholarship slot where you qualify.)
2. Year Entered the University: __________
Current Year Classification: _________
3. College Degree: __________________________________________________________ 4. Have you ever incurred a grade of “4” or “5” in the past two semesters and last mid year if enrolled? (If yes, list the subjects, grades and semesters incurred.) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 5. Did you avail of the STS? _____ (If yes, what tuition fee discount level are you in?) _____ 6. Estimated Gross Family Income of Parents/Guardian (Annual) :___________________
7. Are you receiving any scholarship/grant/assistance? _______ If yes, kindly provide the following details: a. Name of the funding agency: ___________________________________ b. Benefits (in Peso): _________________________________________________ c. Duration: ___________________________________________________ d. Does the funding agency allow you to have other scholarships/grants/assistance? _____ 8. Have you been guilty of participating in any violent incident, whether on campus or offcampus? (If yes, please explain under what circumstances.) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 9. Have you been subjected to any disciplinary action involving a penalty of at least five (5) days suspension, or found guilty of a more serious offense? (If yes, please explain.) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 10. Family Background Name
Relationship
Age
Marital Status
Living with you? (Yes/No)
Occupation
11. Describe briefly why you should be awarded the scholarship/grant applied for? _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
I declare under penalties of perjury that this application has been accomplished in good faith, verified by me and to the best of my knowledge and belief, is true.
__________________________________________ Signature over Printed Name
_________________ Date
Please submit all signed documents in a single .pdf file to
[email protected] 