Form 1 App.

No: 2020-03-29 013003O

Office of the President of the Philippines
COMMISSION ON HIGHER EDUCATION
REGIONAL OFFICE V

CHED SCHOLARSHIP PROGRAMS (CSPs)

APPLICATION FORM

PERSONAL INFORMATION
Name RIVERA Jopit Olavario
(Last Name) (First Name) (Middle Name)
Date of Birth 2002-03-19 Street/Barangay Batbat
Place of Birth Guinobatan, Albay Town Guinobatan
Sex Male Province Albay
Civil Status Single District 3rd
Contact No. 09562542207 Zip Code 4503
Email jopitrivera@gmail.com
FAMILY BACKGROUND
FATHER ( ✔ ) Living ( ) Deceased MOTHER ( ✔ ) Living ( ) Deceased
Name RIVERA Joseph Cortuna Name RIVERA Jeannette Olavario
Address Batbat, Guinobatan, Albay Address Batbat, Guinobatan, Albay
Educational Attainment High School Graduate Educational Attainment High School Graduate
Occupation Barangay Kagawad and Fish Vendor Occupation Housewife
LEGAL GUARDIAN
Name No. of Siblings 0
Address Parent(s)/Guardian Annual Gross Income P 144,000.00
Occupation DSWD's 4ps Beneficiary ( ) YES ( ✔ ) NO
ACADEMIC INFORMATION
Applicant Type A-HS Graduate Year Level in 2020-2021 1
High School Graduated Marcial O. Ranola Memorial School Learner Reference Number 111705070018
College Mariners' Polytechnic Colleges Foundation-Legazpi General Weighted Average 95
Degree Program/Course Bachelor of Science in Marine Engineering
Are you enjoying other source of educational/financial assistance? ( ) YES ( ✔ ) NO
If YES, please specify Type Agency
OTHERS
YES NO
✔ Indigenous and Ethnic People (IP), please specify membership
✔ Dependent of Solo Parent
✔ Persons with Disabilities (PWDs), please specify type of disability

I hereby certify that foregoing statements are true and correct. Any misinformation or witholding of information will automatically disqualify me from the CHED
Scholarship Program. I am willing to refund the financial benefits received if such information is discovered after acceptance of the award.

I hereby express my consent for the Commission on Higher Education to collect, record, organize, update or modify, retrieve, consult, use, consolidate, block, erase
or destruct my personal data as part of my information. I hereby affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my
personal data and be indemnified in case of damages pursuant to the provisions of the Republic Act No. 10173 of the Philippines, Data Privacy Act of 2012 and its
corresponding Implementing Rules and Regulations.

March 29, 2020 JOPIT O. RIVERA

Date Accomplished (Signature over Printed Name)

DOCUMENTS ATTACHED REMARKS

1. Citizenship
( ) Duly certified true copy of Birth Certificate

2. Academic
( ) Duly certified true copy of Report Card - For SH/HS
Graduate
( ) Duly certified true copy of Grades: Grade 11 and 1st
semester of Grade 12 - For Graduating Senior HS

3. Financial
( ) Income Tax Return ( ) Tax Exemption
( )Certificate of Indigency ( ) Case Study
( )OFW Contract

4. Others
( ) Solo Parent ( ) Senior Citizen
( ) IPs ( ) PWD

Evaluated/Processed by

__________________________________ ________________________________
CHED StuFAPs Coordinator Date
 Office of the President of the Philippines
COMMISSION ON HIGHER EDUCATION
REGIONAL OFFICE V

CHED SCHOLARSHIP PROGRAMS (CSPs)

ACKNOWLEDGEMENT RECEIPT

LAST NAME FIRST NAME MIDDLE NAME

RIVERA JOPIT OLAVARIO

ADDRESS
BATBAT, GUINOBATAN, ALBAY, 4503

OPY
DATE OF BIRTH PLACE OF BIRTH SEX CIVIL STATUS
MARCH 19, 2002 GUINOBATAN, ALBAY

' S C MALE SINGLE

ENT
COLLEGE DEGREE PROGRAM/COURSE
MARINERS' POLYTECHNIC COLLEGES FOUNDATION- BACHELOR OF SCIENCE IN MARINE ENGINEERING
LEGAZPI
T U D
APPLICATION ENTRY DATE
MARCH 29, 2020
S
APPLICATION NUMBER
2020-03-29 013003O
GWA
95
FAMILY GROSS ANNUAL INCOME
P 144,000.00

_________________________ ____________________
Received By Date Received

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CSP NOTICE:
CSP applicants are advised to wait for the rank list of the pre-qualified applicants which will be posted at the CHEDROV CSP Official
Website: www.chedro5stufap.com after the application period. Only the pre-qualified applicants based on the rank-list and the
available slots will be required to submit the hard copies of documentary requirements for verification and issuance of Notice of
Award (NOA).

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