Republic of the Philippines

PROVINCE OF NORTHERN SAMAR

2/F New Provincial Capitol
--- Catarman ---

Transformational Leadership for a Renewed Provincial Government of Northern Samar

APPLICATION FORM
ISKOLAR NG PROBINSYA Passport
Size Photo

Note: Please fill out the application form and submit in duplicate to the PGNS Scholarship Committee

New Renewal School Year 20___ - 20___ 1st Semester 2nd Semester

Name: _________________________________________ Age:__________ Date of Birth: _____________________

Home Address: __________________________________________________________________________________
Course/Year: ____________________________________________________________________________________
School: __________________________________________________________________________________________
Contact Number: ________________________________________________________________________________

NAME OF PARENTS OCCUPATION EMPLOYER ANNUAL INCOME

Father:
Mother:

__________________________________ _______________________
Applicant’s Signature Date

ATTACHMENTS: (FOR NEW APPLICANTS)

CERTIFIED TRUE COPY OF CERTIFICATE OF REGISTRATION (COR) of the current

semester, to be obtained from the School Registrar/ Admission Officer (2 copies)

CERTIFICATE OF RESIDENCY AND CERTIFICATE OF GOOD MORAL CHARACTER from

the Office of the Mayor or Barangay Captain (2 copies)

CERTIFICATE OF INDIGENCY from the Municipal Social Welfare Development Office or

Provincial Social Welfare Development Office (2 copies)

ATTACHMENTS: (FOR RENEWAL)

CERTIFIED TRUE COPY OF REPORT OF GRADES of the previous semester, to be obtained

from the School Registrar/ Admission Officer (2 copies)

CERTIFIED TRUE COPY OF CERTIFICATE OF REGISTRATION (COR) of the current

semester, to be obtained from the School Registrar/ Admission Officer (2 copies)

Received by: _______________________________ Date: _______________________

CERTIFIED AS TO THE COMPLETENESS OF REQUIREMENTS

__________________________________ __________________________
In-charge Date