PHILIPPINE-CALIFORNIA

ADVANCED RESEARCH INSTITUTES

SCHOLARSHIP APPLICATION FORM

A.Y, 2015-2016
• A t t a c h h e r e p a s s p o r t size p i c t u r e
t a k e n w i t h i n t h e last 3 m o n t h s

TYPE OF SCHOLARSHIP APPLIED FOR

I 1 M.S. Local [ I Ph.D. Local • Postdoctoral Study Award

• M.S. Overseas • p h
.D. Overseas • Master's Sandwich Program | | Doctoral Sandwich Program

I. PERSONAL INFORMATION

a.

Last Name First Name Middle Name

b.

Permanent address No. Street City/Municipality Province

c.

Zip Code Region District Passport No. E-mail Address

d.

Current Mailing Address

Telephone Nos. (Landllne/Moblle) Fax. No.

Civil Status Date of Birth Age Sex

Name of Father Name of Mother

H. Name of Spouse

Address

Occupation

Office Address

Number of Dependents

(Use additional sheet if necessary)

Name of Dependent Birthday Relation t o Applicant

II. INFORMATION ON CHED & DOST SCHOLARSHIP AND OTHER PREVIOUSLY/CURRENTLY AVAILED OF

SCHOLARSHIP/GRANT YEAR OF AWARD FIELD UNIVERSITY/ SCHOOL REMARKS

DOST-PSHS
MS
OTHERS

CHED-TD

CHED-SNPLP

CHED-DCP

OPAPP-CHED
STUDY GRANT
PROGRAM

CHED-SGP-PA
B.S.
CHED-PAMANA

CHED-SBGP

DOST-RA 7687

DOST-MERIT

DOST-JLAP

OTHERS
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CHED-FDP

CHED-SE6S

DOST-
NSDB/NSTA

DOST-ASTHRD

DOST-ERDT
M.S.
DOST-
COUNCIL/SEI

PCARl

OTHERS

CHED-FDP

CHED-SEGS

DOST-
NSDB/NSTA

DOST-ASTHRD

DOST-ERDT
Ph.D.
DOST-
COUNCIL/SEI

PCARl

OTHERS

III. DEGREE PROGRAMS (For M.S./Ph.D. Applicants Only)

New Applicant

a. University where you applied/

Intend to enroll

b. Course/Degree

Lateral Applicant

a. University enrolled in

b. Course/Degree

c. No, Of units earned d. No. Of remaining units/sems

IV. NOIM-DEGREE PROGRAMS (For Postdoctoral/Stand-alone Sandwich Programs Applicants Only)

POSTDOCTORAL STUDY AWARD

New Applicant

a. University where you applied/

Intend to enroll

b. Degree Earned/University where you earned your degree

Lateral Applicant

a. University enrolled in

b. Degree Earned/University where you earned your degree

c. Research/Project Area

STAND-ALONE SANDWICH PROGRAMS

a. University enrolled in

b. Degree Earned/University where you earned your degree

c. Research/Project Area

d. Overseas University where he/she will conduct the dissertation

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B s
CAREER/EMPLOYMENT INFORMATION
Present Employment Status; Permanent

Self-employed
Contractual

Unemployed
• Probationary

a.l For those who are presently employed

Position

Company

Address

E-mail Website

Telephone No, Fax No,

a.2 For those who are self-employed

Business Name

Address

Email/Website Telephone No. Fax No.

Type of Business Years of Operation

*Once accepted into the scholarship program, the scholar must obtain permission t o take a Leave of Absence (LOA) from his/her employer and become a full-time
student. The scholar must submit a letter f r o m his/her employer approving the LOA.

b. Narrative on Applicant's Current Work, Outstanding Qualities, Career and Research Plans (Write in separate sheet attached to this form)

b.l Provide a narrative of not more than one thousand (1000) words, describing the applicant's current work or project (or research) that s/he worked
on and his/her contribution towards the completion of the project.

b.2 Provide a narrative of not more than five hundred (500) words, describing the qualities that make (you) the applicant outstanding in a highly
competitive process (e.g., academic excellence, development potential, financial need, etc.)

For Master's Scholarship applicant, a narrative, not more than five hundred (500) words, describing his/her intended research area and what the
applicant intends to do (e.g., work, business, etc.) after earning his/her graduate degree. For Doctoral Scholarship and Postdoctoral Fellowship
applicants, a narrative, not more than 500 words, describing his/her intended research area, e.g., a "Statement of Purpose".

VI. RESEARCH AND DEVELOPMENT INVOLVEMENT (last five years)

Use additional sheet i f necessary.

FIELD AND TITLE OF RESEARCH LOCATION/DURATION FUND SOURCE NATURE OF INVOLVEMENT

VII. PUBLICATIONS (last five years)

Use additional sheet if necessary.

TITLE OF ARTICLE/PUBLICATION PLACE/YEAR OF PUBLICATION NATURE OF INVOLVEMENT

VIM. AWARDS RECEIVED

Use additional sheet if necessary.

TITLE OF AWARD AWARD GIVING BODY YEAR OF AWARD

I hereby certify t h a t all information given above are true and correct t o the best of my knowledge.

Signature of Applicant

Date
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CHECKUST OF REQUIRED DOCUMENTS SUBMITTED (for staff use only) • Admission letter (Note: For overseas scholarship, admission fetter will only
be required from pre-qualified applicants.)
D Curriculum vitae covering personal, educational (including research • Medical Cerificate from a licensed physician indicating PRC License No.
projects if applicable),and professional {type of work and position occupied) 0 Grades or official transcript of records
background. • Diploma or certificate of graduation
• Recommendation tetter from three (3) past professors or supervisors Certification of no pending cases from
0 Birth certificate (original N50 copy and photocopy) • N8i
• Employer (University for new graduates)

Staffs Signature

Date: