CHED-Scholarship Application Form

2019 version (NOT FOR SALE) ANNEX "A"

Office of the President of the
Philippines COMMISSION ON HIGHER
EDUCATION REGIONAL OFFICE
2X2
ID PICTURE
CHED SCHOLARSHIP PROGRAM (CSP)
APPLICATION FORM
Instructions: Read General and Documentary Requirements. Fill in all the required 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
CRITERIA OF ELIGIBILITY per CMO 08 s. 2019 DOCUMENTARY REQUIREMENTS per CMO 08 s. 2019
1.Filipino citizen; Academic Requirements - any one of the following:
2.Graduating high school students/High school graduate ( ) 1. High school report card
3 General Weighted Average (GWA) of at least 90% or above. ( ) 2. Duly certified true copy of grades for Grade 11 or 1st semester of Grade 12 for
4 Combined annual gross income of parents/guardian not to exceed graduating high school students
Four Hundred Thousand Pesos (PhP400,000.00) or
solo parent/guardian whose annual gross income does not Income Requirements - any one of the following :
exceed the said amount; ( ) 1. Latest ITR of parents or guardian if employed ( )
In highly exceptional cases where income exceeds 2. Certificate of Tax Exemption from the BIR
Php400,000.00, the CHEDRO StuFAPs Committee shall ( ) 3. Certificate of Indigency from their Barangay (
determine the merits of the application ) 4. Certificate/Case Study from DSWD
5 Avail of only one government funded financial assistance ( ) 5. Latest copy of contract or proof of income for children of Overseas Filipino
program. Workers (OFW) and seafarers.
NOTE: Beneficiaries of free higher education under RA 10931 can only receive stipend under this program
PERSONAL INFORMATION

1. Name
(Last Name) Maiden Name
(First Name) (Middle Name)
put extension, if any: i.e. Jr., (for Married Women)
III
2. Date of Birth (mm/dd/yy)
3. Place of Birth 9. Present Address

4. Sex □ Male □ Female 10. Zip Code

□ Single □ Widowed
□ Married Separated 9. Permanent Address
5. Civil Status □
□ Annulled Others
□
10. Zip Code
6. Citizenship
11. Name of School Last Attended
7. Mobile Number
12. School Address
8. E-mail Address
13. School Sector:
( )Public ( )Private 15. Type of Disability (if applicable)
14. Highest Attained Grade/Year Level
16. IP affiliation (if applicable)

FAMILY BACKGROUND
Father: ( ) Living ( )Deceased Mother: ( ) Living ( ) Deceased Legal Guardian
17. Name
18. Address
19. Contact Number
20. Occupation
21. Name of Employer
22. Employer Address
23. Highest Educational Attainment
24. Total Parents Taxable Income 24. No. of Siblings in the family 18 years old and below

25. Is your family a beneficiary of the DSWD's pantawid Pamilyang Pilipino Program (4Ps)? ( ) Yes ( ) No

26. School Intended to enroll or enrolled in:

27. School Address:
28. Type of School: ( ) Public ( ) Private
29. Degree Program:

Type Grantee Institution/Agency

30. 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 please specify type of disability
2. Financial
indigenous and ethnic peoples please specify membership
( ) ITR ( ) Tax Exemption ( ) Certifcate of Indigency
( ) Case Study DSWD ( ) OFW Contract
3. Others
( ) Solo Parent ( ) Senior Citizen ( ) IPs ( ) PWD
School intended to enrol in
School address
Type of School ( ) Public ( ) Private
Course
( ) Priority ( ) Non-Priority

Evaluated/Processed by:
CHED StuFAP Coordinator Date