SIGNED DECLARATION BY THE APPLICANT & PARENTS / LEGAL GUARDIAN
We hereby certify the truthfulness and completeness of the information we have stated above. Any
misinformation/misrepresentation or withholding of information will automatically disqualify and/or terminate
the scholarship grant of the undersigned applicant from the Rizal College Scholarship rogram. !n connection
with this" !/We hereby authorize the Rizal rovincial #overnment to conduct bac$ground chec$ on the family
%nances and to visit our residence.
________________________ __________________________ ____ ____________________________
Applicants Signature Fathers/Guardian Signature Mothers/Guardian Signature
___________________________
Administering Ofcer
R!&A' R()!*C!A' #()+R*,+*-
Rizal College Scholarship Program
APPLICATION FORM FOR 2010-2011
FAMILY BACKGROUND
.A-/+R/#0AR1!A* ,(-/+R/#0AR1!A*
*ame
/ighest +ducational
Attainment
(ccupation
+mployer
,onthly .amily !ncome
Annual .amily !ncome 23ear
45567
(ther Source of
!ncome
*o. of Children/1ependent in
the .amily
-heir Ages
RELATIVE ENJOYING ANY COLLEGE SCHOLARSHIP GRANT
*A,+ R+'A-!(*S/!
R(#RA,/S(*S(R 3+AR/
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ACA1+,!C 8AC9#R(0*1
*ame of School Address 3ear
+'+,+*-AR3
/!#/ SC/(('
to !e cut !" RCSP Coordinator
Rizal College Scholarship rogram #$o no %ll this area to !e %lled up !" RCSP Coordinator&
TEST PERMIT
Name:_____________________________________ Gender:___ Room No.____Seat No.___
School:__________________________________________________________________
This is to certify that the above applicant is qualified to take the Qualifyin !"amination
on #anuary $%& '($(& ):(( a.m to be held at ___________________________.
_________________
Ruby A. Barroga ________________________________
Scholarship *oordinator *hairperson& Test +dministration *ommittee
PERSONAL DATA
*A,+: #'AS(& #F)RS(& #M)$$'*&
8!R-/1A3: A#+:
#+*1+R:
8!R-/'AC+: R+'!#!(*:
A11R+SS: *o./St. 8rgy:
,unicipality:
*umbers of years residing in Rizal: -el. *o. /Celphone *o.:
INTENDED DEGREE PROGRAM / COLLEGES & UNIVERSITIES
*ame three 2;7 degree courses/program of study you wish to pursue
<
st
Choic
e
4
nd
Choice
;
rd
Choice
*ame three 2;7 schools where you wish to study 2Schools must be located in Rizal rovince and
,etro ,anila Areas. -he campuses of 0niversity of the hilippines 207 located in 'os 8anos =
8aguio are considered
<
st
Choic
e
4
nd
Choice
;
rd
Choice
R*M)+$*R,
Please %ll up all re-uired in.ormation legi!l" and a/oid erasures0
Su!mit #1& cop" o. this .orm0 (*'3 A'!CA-!(*
ACC(,'!S/+1 C(RR+C-'3 A*1 C(,'+-+'3 W!-/
R+>0!R+,+*-S W!'' 8+ R(C+SS+1.
*(- .(R SA'+
(his .orm can !e print in !ac2to
!ac2
$ate o. *3am, 4anuar" 156 7818
$ate o. Su!mission, $ecem!er 916
A((AC: R*C*+(
7;7 P:O(O <ith
name
A((AC: R*C*+(
7;7 P:O(O <ith
name
only wa! "# $B%#! &or R"'al(
, )o*. +un ,nar%#
REQUIREMENTS
Copy of Birth / Baptismal Certificate
For PRIVATE & PUBLIC schools students whose parents are GAINFULLY EPL!YE"#
$%& BIR For' ()%* $Cert+,+cate o, Ta- .+thheld& ,or FY (//0 w+th an annual +nco'e o, not 'ore than P%(/1///2//
For PRIVATE schools students whose parents are N!T GAINFULLY EPL!YE"#
$%& cop3 BIR Cert+,+cate o, TA4 E4EPTI!N ,or FY (//05 (//6 $authent+cated cop3&
For PUBLIC schools students whose parents are N!T GAINFULLY EPL!YE"#
$%& cop3 Baran7a3 Cert+,+cate o, Ind+7enc3 $ !r+7+nal &
recent (-( photo w+th na'e
NAME:__________________________________________________________________________________________________________________
(Last, First, Middle)
School:______________________________________________________ School Address:_____________________________________________
DECLARANT RELATIVE/S WORKING IN THE GOVERNMENT
*A,+ R+'A-!(*S/! (S!-!(* (..!C+ A11R+SS
NOTE: ANY ERASURE ON TE !RA"E OF TE A#O$E%NAME" A&&LI'ANT (ILL IN$ALI"ATE TE A&&LI'ATION UN"ER TE R'S&)
MAT: S'IEN'E: EN!LIS: FILI&INO: ARALIN!
&ANLI&UNAN:
W+!#/-+1
A)+RA#+
#RA1+:
BARANGAY CERTIFICATE OF RESIDENCY
(his is to certi." that __________________________________ is a resident o.
__________________________________________________Pro/ince o. Rizal6 since _____________0
(his certi%cation is issued upon the re-uest o. said__________ in connection <ith his/her scholarship application in Rizal
College Scholarship Program0
_______________________________________________
Printed +ame = Signature o. the >aranga" Captain
>aranga" Seal
R+,!*1+R:
Please <ear "our :)G: SC:OO' ?+)FORM on the *3amination
$a"
Please !ring the .ollo<ing on the *3amination $a"
a0 (his Permit
!0 @our :igh School )0$
c0 >lac2 or >lue >all pens and pencil
d0 Pac2ed lunch6 drin2ing <ater6 Auices6 sand<iches and
candies
CERTIFICATE OF GOOD MORAL CHARACTER
(his is to certi." that __________________________________ has consistentl" maintained good moral character0 (here ha/ing no
disciplinar" action ta2en against him/her as to date0
_______________________________________________________
Printed +ame = Signature o. the Scholarship Coordinator
School Seal
CERTIFICATION
(his is to certi." that the grades o. __________________________________ .or the 7
nd
Grading Period .or %/e #B& maAor su!Aect
areas and the Ceighted A/erage Grade #CAG&6 has !een made in good .aith and /eri%ed !" us to !e true and correct0
__________________________________ __________________________________
Printed +ame = Signature o. Class Ad/iser Printed +ame = Signature o. the Principal
School Seal
