Application Form - NEW

GO-EDUC4-01
Rev. 04
Republic of the Philippines
PROVINCE OF ILOCOS SUR Recent
Heritage City of Vigan 1.5 x 1.5 ID Picture
Taken within the last
3 months
ILOCOS SUR EDUCATIONAL ASSISTANCE & SCHOLARSHIP PROGRAM (White/Red Background)
APPLICATION FORM 1
Control No.
Instructions: Date of Filing
1. Print all entries

2. Place (X) in the appropriate space provided
1. All photocopied documents should be faithful reproduction of the original. Bring the original copies of the documents for
validation purposes.
2. Fill up ALL the data requirements in the Application Form and submit ALL the documents required during the Application.
Incompletely filled-up Application Forms or those with incomplete requirements shall NOT be accepted, or IF inadvertently
accepted, it shall NOT be processed.
3. Submit Application Form at the E.S.A. Secretariat.
4. Please do NOT wait for the last day of the application period if you do not want to be inconvenienced, or worse rejected.
Requirements:
Certification from the Barangay Chairman that the Photocopy of Latest Income Tax Return of Parents or
applicant is a bonafide resident of the barangay for at least Certification of Exemption from the Bureau of Internal
one (1) year and has no derogatory record/s. Copy of latest Revenue (BIR) stating the annual gross income. If Parent/
grades with General Average of 2.25 or 83%. Legal Guardian is a retired employee, submit retirement
Two (2) Copies of 1.5” x 1.5” picture taken within the last
form and/or pension voucher. If parents are not filing
three (3) months with WHITE background. Print your name
income tax, acquire a Certificate of Indigency from your
at the back of each photo and affix your signature above
barangay of residency.
your name.
Copy of Certificate of Good Moral Character
A. PERSONAL BACKGROUND
Surname: First Name: Middle Name: Ext.(e.g. Jr., III)
Gabaon Robinson Sagun
Permanent Address:
Ayusan Norte Vigan City, Ilocos Sur
Present Address:
Ayusan Norte, Vigan City, Ilocos Sur
Birthdate: (mm/dd/yyyy) Age: Sex: Civil Status: Religion: Contact No:
July 13, 2001 21 Male Single Roman Catholic 09923536807
Course/Course Preference: Year Level: GWA (last SEM)
College of Tecgnology 1st Year 83.00
School/College/University Preference: University of Northern Philippines
Ilocos Sur Community College Ilocos Sur Polytechnic State College
Main Campus Demofarm
Sta. Maria Campus Tagudin Campus
University of Northern Philippines
Cervantes Campus Narvacan Campus
North Luzon Philippines State College
Candon City Campus Santiago Campus
Are you a recipient or have applied for another Scholarship other than this? YES NO
 If YES, please specify the nature of the other Scholarship Grant:

B. EDUCATIONAL BACKGROUND
Year Honors/Awards
Name of School School Address
Graduated Received (If any)
Secondary Ilocos Sur National High School 2022
Elementary Paoa Elementary School 2016
C. FAMILY BACKGROU ND
Father Mother Guardian

Living / Deceased / Living Deceased
Name Romulo Gampayon Imelda Gabaon Angela Gampayon

Occupation n/a Vendor Newly Graduate
Place of Work n/a None None
Highest Educational Attainment High School Graduate High School Graduate College Graduate
Contact No. n/a 09358863563 09551234114
Ave. Monthly Income n/a 8,000 None
ESA Form 001
Numbers of siblings in the family: ( Eight ) Please fill out information below about your siblings.
Highest Educational Highest Educational
Name of Brother/s Age Name of Sister/s Age
Attainment Attainment
Rommel Gampayon 18 Grade 8 Angelica Gampayon 27 College Graduate
John Lloyd Gampayon 15 Grade 7 Querobin Gampayon 26 College Graduate
Prince Rum Gampayon 10 Grade 4 Angela Gampayon 23 College Graduate
Althea Mendoza 2 n/a
Do you have any brother / sister who is also a recipient of the Ilocos Sur Educational Assistance and Scholarship Program?
YES / NO If YES, state the Name, Year & Course and School where he/she is currently enrolled as scholar
STATEMENT OF APPLICANT
I hereby certify to the veracity of all information I have provided. I understand that any false disclosure, misinterpretation,
concealment of material facts and / or withholding any relevant information will be tantamount to disqualification from the
Scholarship Program of the Provincial Government of Ilocos Sur.
Moreover, I understand that the Scholarship Committee may send a fact-finding team to visit my home / residence to
verify the truthfulness of the information provided in this application and I will give my utmost cooperation in this regard. I
understand that my refusal to comply with any of these herein stated terms and conditions may mean disqualification or withdrawal of
Scholarship Grants & Privileges.
Date: July 19, 2022 Robinson Gabaon

Applicant’s Signature over Printed Name
STATEMENT OF APPLICANT’S PARENTS / GUARDIAN
I hereby verify to the truthfulness and completeness of the information which my son / daughter / dependent has
furnished in this application together with all the documents attached. I further recognized that in signing this application form, I
share my son / daughter / dependent the responsibility for the truthfulness and completeness of the information provided herein.
Moreover, I understand that the Scholarship Committee may send a fact-finding team to visit my home / residence to
verify the truth of the information provided in this application and I will give my utmost cooperation in this regard. I understand that
my refusal to comply with any of these herein stated conditions may mean disqualification or withdrawal of Scholarship Grants &
Privileges due to my son / daughter / dependent.
Date: July 19, 2022 Imelda Gabaon

Parent/Guardian’s Signature over Printed Name
Received by: Reviewed by: Recommending Approval:
____________________________ ___________________________
ESA Secretariat In-charge Chairman
Date: Education and Scholarship Affairs Committee on Education
Approved by:
___________________________
Governor
Important Notice:
1. Scholarship privilege will be withdrawn from an applicant who withhold and/or falsifies information.
2. For old or continuing scholarship grantees, be sure to participate / take part in the different programs or activities of the
Provincial Government at least two for every semester.
3. Upon enrolment, submit a photocopy of your ENROLMENT FORM. Failure to submit means cancellation of applicant's name
in the Provincial Scholars Master list.

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GO-EDUC4-01

1. Print all entries

 If YES, please specify the nature of the other Scholarship Grant:

Elementary Paoa Elementary School 2016

Father Mother Guardian

Name Romulo Gampayon Imelda Gabaon Angela Gampayon

ESA Form 001

Date: July 19, 2022 Robinson Gabaon

STATEMENT OF APPLICANT’S PARENTS / GUARDIAN

Date: July 19, 2022 Imelda Gabaon

Received by: Reviewed by: Recommending Approval:

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