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INTERSESSION 2019 REQUEST FORM

DEADLINE FOR SUBMISSION: FRIDAY, APRIL 26, 2019

NAME:
Last First Middle
ID: INCOMING YEAR and Course: Contact No:

TYPE OF SCHOLARSHIP:  ACAD  AFMS/SIDL  ATH  DIRLIST  DOST ONLY  FIN-AID


NOTES:
1. The scholarship support for the Intersession Term will cover only subjects required by the program for this particular term, NOT subjects re-taken
because of failures, withdrawals or shifting of concentration or subjects to be taken in advance even though advised for the Intersession Term by
the Department.
2. For those who took basic courses, subjects displaced are covered.
3. Dorm scholars with no Intersession Term classes but with required Practicum must submit a request letter for dorm scholarship together with
this form.
4. For incoming Juniors, Seniors & Fifth year scholars, please list at the back side of this form all subjects taken the past Intersession/Summer terms.
5. If you need any additional financial aid for Intersession 2019, please write a separate letter noted by your parents.

I am requesting that my scholarship cover the following subjects required by my curriculum to be taken
specifically this Intersession Term 2019:

CAT NO. COURSE TITLE # of UNITS

Please answer the following when applicable:


1. Did you take any Basic Courses?  Yes  No
If yes, please identify the basic subjects that you took:
2. Did you fail or withdraw from any subject?  Yes  No
If Yes, identify the subject/s and grade/s incurred (F or W): _______ __
3. Did you miss enrolling in any subject/s in the past Intersession/Summer terms because you lost out on class slot/space or
because you took required subject/s displaced as a result of taking your Basic course/s?
 Yes  No If Yes, which subjects should you take this Intersession 2019 to be able to catch up:

CAT NO. COURSE TITLE # of UNITS

Signature of Scholar Signature of Parent/Guardian Date

DECISION: APPROVED: # of Units: DISAPPROVED:


NOTE: Date:

G/F Kostka Hall, Katipunan Ave, Loyola Heights, 1108 Quezon City, Philippines
+63 2 426 6001 ext 5154 to 5155 • Fax +63 2 426 1214 • admissions.ls@ateneo.edu