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Name
(Last Name) (First Name) (Middle Name)
Age: Sex: Status: Religion: Citizenship:
Date of Birth: Place of Birth:
Mailing Address: Contact Number:
Home/Provincial Address:
School Name (High School):
School Address:
School Type: ( ) Public ( ) Private ( ) Vocational
Highest Grade/Year: Date of Graduation: Rank in Class:
National Career Assestment Examination (NCAE) Score: Date of Exam:
Academic Awards/Honors Received:
FAMILY BACKGROUND
Name:
Address:
Occupation:
Educational Attainment:
Tribe Membership (for SP-IEP only):
Authenticated certificate from OPAPP (OPAPP-CHED SGP-RR only)
Total Parents Gross Income: (ITR for 200____ attached)
Brothers/Sisters Enjoying Scholarship:
Name: Scholarship Course and Year
I/ We hereby certify to the truthfullness and completeness of information provided. Any misinformation or witholding information will automatically disqualify
my/ our child from the CHED Scholarship program. I/ We are also willing to refund all financial benefits rfecieved plus the appropriate interest such
misinformation is discovered/ our child accepted the reward.
In connection with this application for financial aid, I/we hereby authorize CHED-OSS/CHEDRO to conduct a background check on the family finances and
to visti our family dwelling
Applicant's Signature Over Printed Name Parent's or Guardian's Signature over Printed Name
Date
Note: Fully accomplished form to be submitted to CHEDRO Caraga, NORMISIST Campus, Ampayon, Butuan City on or before April 15 ara'07
Incomplete applications will not be processed. See the requirements at www.chedcaraga.com or @ http://chedscholars.blogspot.com