CHECKLIST OF DOCUMENTS SUBMITTED

For Scholarship Coordinator/staff use only

Applicant’s Name (SN, FN, MN, Suffix Name):______________________________________________________

GENERAL DOCUMENTARY REQUIREMENTS
1. Accomplished Application Form
2. Two recent photographs (1x1 inches) taken within the month of application
3. Certificate of Good Moral Character
4. Certification of Good Health
5. Parent’s Certification (If no pending application for immigration)
6. Photocopy of Birth Certificate (PSA)
7. (For Merit-based) Parent/s 2019 Income Tax Return / W-2 / Employment Contract for OFW / BIR

(For Financial assistance) Parent/s Certificate of Exemption for Filing of ITR / Municipal or
Barangay Certificate of Indigency

8. Latest Statement of Assets and Liabilities of parents (if applicable)

9. Applicant’s Certificate of Residency
10. Affidavit of guardianship (if with legal guardian)
11. Photocopy of 3 months electric bill

FOR FRESHMAN YEAR APPLICANT

A. Principal’s Certification
For STEM strand: Must reflect that the applicant is a candidate for the Grade 12 graduation
under the STEM Strand of the (name of the school) for the (school year).

For Non-STEM strand: Must reflect that the applicant is a candidate for the Grade 12 graduation
under the (specify Non-STEM strand) for the (school year) and is classified within the upper five
percent (for merit-based) / 10 percent (for financial assistance) of (indicate total number of
students) in the graduating class.
B. Photocopy of grades in Grade 12
C. Certified true copy of the entrance exam result issued by the university

FOR SECOND YEAR OR UPPERCLASSMAN APPLICANT

A. Certified true copy of grades from the University Registrar/College Secretary’s office

This application form and attached documents

were verified for completeness by: _______________________________________________
SIGNATURE OVER PRINTED NAME
Date:_________________

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 DEPARTMENT OF AGRICULTURE BIOTECHNOLOGY
UNDERGRADUATE SCHOLARSHIP PROGRAM
For UPLB Undergraduate Students specializing
in Biotechnology related programs
1x1
ID Picture
APPLICATION FORM
INSTRUCTION: Please completely and carefully accomplish the application form. If applicable, write legibly in
BLUE INK and CAPITAL letters or put a check that corresponds your answer. Otherwise, put N/A. Applications
without required documents or with incomplete information will NOT be processed. Rest assured that all given
information will be kept confidential.

A. SCHOLARSHIP TYPE REQUEST

1. Scholarship Type: __Financial Assistance Scholarship __Merit-based Scholarship

2. Did the applicant receive any scholarship in high school? __Yes __No
3. [For old freshman or upperclassman] Is the applicant enjoying scholarship/financial assistance prior to his/her
application for item no.1? __Yes __No
If yes, in what year levels and semesters: _____________________________________________________
Please specify nature and amount of grant/s:__________________________________________________

B. PERSONAL INFORMATION

4. Applicant’s Name (Surname, First Name, Middle Name, Suffix Name):

5. Sex: _Male _Female 6. Year, Semester, and Course:

7. Birth date (DD/MM/YYYY): 8. Place of Birth: 9. Age: 10. Student No.:

11. Permanent Address (House/Unit No., Street, Lot/Blk, Village/Barangay, City/Municipality, Province, ZIP code):

12. Mobile Number(s): 13. Email Address:

15. Civil Status:

14. Citizenship: _Filipino _Dual (specify):____ _Others: specify):____
16. College: 17. If the student is not living in item 11, where does s/he intend to live while studying in
the university? Please check one:

_University Dorms _Off-campus boarding house _With a relative

_Others (specify):_____________

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 B.1 FOR INCOMING FRESHMAN APPLICANT Note: Please leave blank if not applicable.

Name of School: Address of School:

Type of School: _Regular HS _Science HS _Private HS _University/College-based SHS

Senior HS Strand: _STEM _NON-STEM Please specify:___________________________

School Year Grade 12 Rank in Graduating Total no. of College admission test
graduated: GWA: Class: Graduates: rating:

B.2 FOR UPPERCLASSMAN APPLICANT Note: Please leave blank if not applicable.

General Weighted Average: Total Units Earned:

Major: Minor:

C. FAMILY DATA

18. PARTICULARS FATHER MOTHER LEGAL GUARDIAN /

STEPPARENT
If applicable; must submit affidavit of
guardianship
Name (Surname, First Name, Middle
Name, Suffix Name)
Mobile number
Age (If deceased, when)
Please indicate civil status:
solo-parent, widowed, married,
separated
Highest Educational Attainment
Occupation
Name of employer
Employer/agency’s address
Position and number of years
in the company
2019 Annual Gross Income
(in pesos; taxable and non-taxable)
If self-employed, state nature
of work

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 If self-employed, indicate 2019
Annual Gross Income
If unemployed, since when and
reason for unemployment
If retired, when and under
which company
Is your household included in the DSWD Listahanan 2.0? _Yes _No
(If yes, please provide clear photocopy of your DSWD ID.)

Is your family a beneficiary of DSWD’s Pantawid Pamilyang Pilipino Program (4Ps)? _Yes _No
(If yes, please provide clear photocopy of your family’s 4Ps ID.)

19. No. of children in the family:________________

20. Birth order of the applicant (1st child, 2nd child… youngest, only child):_________________________

21. Siblings no longer in school / who are employed (Please use separate sheet if needed.)

Name
Age
Civil Status
Residing with the family?
_ Yes _No _ Yes _No _ Yes _No _ Yes _No _ Yes _No
Number of dependents
Highest educational
attainment
Scholar?
_ Yes _No _ Yes _No _ Yes _No _ Yes _No _ Yes _No
Occupation
Name of employer
Employer/agency’s
address
Position and number of
years in the company
2019 Annual Gross
Income (in pesos;
taxable and non-taxable)
If self-employed, state
nature of work
If self-employed, indicate
2019 Annual Gross
Income
If unemployed, since
when and reason for
unemployment

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22. Siblings still in school / not yet studying (include applicant) (Please use separate sheet if needed.)

Name
Age
Grade / Year Level
Approx. yearly
tuition and
miscellaneous fee
Amount covered by
parents
Amount covered by
scholarship
Amount covered by
other financial
support

23. Other dependents living with the family:________________________________________________________

__________________________________________________________________________________________

24. Name the persons (relatives, friends, etc.) who help with the family household and educational expenses?

Name
Relation to the
applicant
Purpose of
financial
contribution
(e.g. educational
assistance, household
expenses assistance,
etc.)
Duration (site
year/date) and
extent of
support (e.g.
monthly, quarterly,
semi-annual,
annual, irregular)
Amount of
support (e.g. PhP
10,000 per month,
PhP 10,000 per
quarter, etc.)

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 FULL VIEW OF THE HOUSE FAÇADE
(Please attach clear full view of the applicant’s permanent
residence in 3R or 3.5” x 5” size.)

MAIN KITCHEN WITH REFRIGERATOR IN PHOTO

(Please attach clear photo of kitchen in 3R or 3.5” x 5” size.)

FULL VIEW OF BUSINESS ESTABLISHMENT

(IF APPLICABLE; in 3R or 3.5” x 5” size)

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 D. FAMILY FINANCIAL STATUS
25. Annual Gross Income (in pesos) 26. Family Monthly Expenses

Father Food/Grocery
Mother House rent/Amortization
Commissions Electricity bill
Profit on Business Water bill
Profit on land rentals Telephone, Internet
Profit on building/residence TV cable
rentals
Interest income Mobile phone load
Dividends School and/or Work
Allowance
Financial support from children Transportation Allowance
(including fare and gas)
Financial support from relatives Tutorials (academic, musical,
sports)
Financial support from others Helper/Driver salary, if
applicable
Pension Debt/Loan payments
Others Please specify: Recreational expenses (e.g.
dining out, watching movies,
shopping, etc.)
Others Please specify: Others Please specify:

TOTAL ANNUAL FAMILY (A) Subtotal Annual

GROSS INCOME: Family Expenses:

27. Family Yearly Miscellaneous Expenses

Clothing
Home Repair/Improvement
Insurance
Medical/Dental
School supplies/books expenses
School Tuition and other fees
SSS/GSIS, Pag-ibig, PhilHealth contributions
Others Please specify:
Others Please specify:
(B) Subtotal Yearly Family Expenses:
TOTAL ANNUAL FAMILY EXPENSES (add A and B):

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28. Do you/your family own a business? __ Yes (If yes, please fill out the table below.) __No

Type of Name of Date started No. of Capital Monthly Net Annual Net
Business Business employees Invested Profit Profit

29. Does the applicant have a part-time job? __ Yes (If yes, please fill out the table below.) __No

Type of Job Name of Employer Contact No. of the Hours per week Monthly Income
or Agency Employer or
Agency

30. On the average, how much is the budgeted monthly school allowance of the applicant?________________

E. HOUSEHOLD DATA

31. Permanent Residence

Type: __House __Apartment __Condominium

Ownership: __Family owned, fully paid __Family owned, amortized __Rented

__Free housing provided by the company/government __Rent free/Living with relatives/friends

Name of Owner Relationship to the applicant Length of Stay

Date Acquired If rented, how much is the If amortized, how much is the monthly
monthly rental? amortization?

If the unit was renovated, how much was spent? Acquisition Cost, IF OWNED

32. Does your family own agricultural land or non-residential land? __ Yes (If yes, please fill out the table below.) __No
Location Size Date Acquired Acquisition Cost Present Market Value

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33. Household Possessions (Please do not leave blank.)

Items Quantity Date Acquired Acquisition Cost Balance to be still paid

Air-conditioner
Gas range/electric
stove
Laptop/netbook/PC
Table e.g., IPAD,
Kindle, Nexus, etc.)
Refrigerator/freezer
TV set
Washing
Machine/dryer
Microwave oven

34. Does your family own vehicle/s? __ Yes (If yes, please fill out the table below.) __No

Type No. of Year Model Make Name of Owner Relationship to Acquisition Balance to
Working (e.g., 2000, (e.g.,Honda, the applicant Cost be still paid
Units 2019) Mitsubishi,
etc.)
Tricycle
Passenger
Vehicle
(e.g., jeepney,
van, etc.)
Car/AUV/SUV
Truck/Bus

F. REFERENCE

35. Please list down two (2) persons who know your family very well and whom the Scholarship Committee may
coordinate with for possible inquiry.

Full Name Address Relation/Position Contact Numbers

(e.g., neighbor, Brgy. Kagawad, etc.

Page 9 of 10
SIGNED DECLARATION BY THE APPLICANT AND PARENTS/LEGAL GUARDIAN

I/We hereby certify that all the information provided here is COMPLETE, TRUE, and CORRECT. I/We hereby
authorize the Department of Agriculture-Biotechnology Program Office, through the University Scholarship
Committee, to verify the same via an official inquiry if needed.

I/We understand that any misinterpretation of information or withholding of information requested in this
questionnaire will be considered sufficient reason for disapproval or cancellation of the scholarship grant. I/We
are willing to refund all the financial benefits received if such misinformation is discovered after my/our child
accepted the grant.

I/We authorize the Department of Agriculture-Biotechnology Program Office and the University Scholarship
Committee to control and instruct their duly authorized personnel to process all the information we provided,
including collecting, recording, organizing, storing, updating, modifying, retrieving, consolidating, sharing,
blocking, omitting, or using the information and/or documents given in any other way necessary to pursue its
legitimate interests in relation to our application for the scholarship grant.

I/We understand that we have the right to be informed, object to processing, access and rectify, suspend or
withdraw my/our personal data, and be indemnified in case of damages pursuant to the provisions of R.A. 10173
of the Philippines (Data Privacy Act of 2012) and its corresponding implementing Rules and Regulations.

Applicant’s signature over printed name: ________________________________________ Date signed:______

Father’s signature over printed name: ___________________________________________Date signed:______

Valid I.D.*:_______________ I.D. No.:__________________________

OR

Mother’s signature over printed name: __________________________________________ Date signed:______

Valid I.D.*:_______________ I.D. No.:__________________________

OR

Legal Guardian’s signature over printed name: ___________________________________ Date signed:______

Valid I.D.:_______________ I.D. No.:__________________________

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