Republic of the Philippines

QUEZON CITY
Office of the City Mayor
Scholarship and Youth Development Program

APPLICATION FORM
00 ss
Photo

2” X 2”

With nameplate

ID Picture taken
within the last 6
months

Instructions: READ ADMISSION AND APPLICATION REQUIREMENTS AT THE BACK PAGE. Fill in all the required information. DO NOT leave an item blank. If
item is not applicable, indicate “N/A”. All applications must be filed PERSONALLY by applicant.
A. Personal Information
Last Name O L L E R O Ext Name M.I
i.e JR/SR, if any (D,P, or DP)

First Name J A K E Sex Female Male

Middle Name Civil
(e.g.De La Paz = D, P, or
DLP; Dela Paz) R O M E R I C A Status
Date of Birth (MM/DD/YYYY) Place of Birth (City/Municipality) Religion Height (meter) Weight (kilogram)
1 0 - 0 2 -2 0 2 0 Roman Catholic
B. Current Demographic Data
Complete Address Barangay District City Zip Code

Landline Number N A - Mobile Number 0 9 5 6 - 7 0 1 - 9 3 9 2

Email Address [email protected] Facebook Account Luke Ollero
C. Family Economic Data
Head of the Family Juanito Ollero Estimated Monthly Income
D. Last School Attended Data

Name of School Basic Education / Academic Award or Honor Period of Attendance GWA
(Write in full) Degree / Course Received From To GENERAL WEIGHTED AVERAGE

E. Name three (3) Schools and Courses you wish to enrol in

School Course
School Course
School Course
F. Community Involvement / Affiliation
Name of Organization Position Inclusive Dates Nature of Organization

G. Consent

I hereby give my consent on the general use and sharing of personal and sensitive personal information I have provided herein
in accordance with the declared objectives of the Organization/Party at its inception and as adopted annually. The Organization/Party
can collect, process, store, update, or disclose this information for legitimate purposes and for implementing the programs of the
Organization/Party.
I consent to the continuous use and retention of this information by the Organization/Party for a period of five (5) years from the
receipt of the latter of my notice of severance from the Organization/Party.

_____________________________________________ __________________________
SIGNATURE OVER PRINTED NAME OF APPLICANT DATE

THIS FORM IS NOT FOR SALE Page 1 of 2

 ADMISSION REQUIREMENTS APPLICATION REQUIREMENTS

Who may avail of the Service: GENERAL REQUIREMENTS:

 Quezon City Residents [ ] Certified True Copy of Birth Certificate
Academic Category [ ] Certified True Copy of Form 137 or 138 / Grade Slip
 Overall Rank 1 to 10 from Quezon City Public Senior High [ ] Barangay Certification
Schools [ ] Latest Income Tax Return of Parents /Affidavit of Non-filing
[ ] 2x2 latest ID photo with nameplate (2pcs)
Civic Leaders Category [ ] Long White Folder with plastic jacket
 Sangguniang Kabataan (SK) Officials
 Centrex Graduates ADDITIONAL REQUIREMENTS:
 Supreme Student Council Officials
 School Publication Officials Academic and Senior High School Category
[ ] Certificate of Honor / Award
 Scout Leaders
Economic and Financial Assistance Category Civic Leaders Category
 QC Public/Private High School Graduates with at least 75% [ ] Certificate of Supreme Student Council / Centrex / Sangguniang
general weighted average Kabataan
 ALS Graduates
 Solo Parents Economic and Financial Assistance Category
 Household Helpers [ ] If PWD: Medical Certificate
 Persons with Disabilities (PWD) [ ] If Kasambahay: Certificate of Employment
 College Students [ ] If ALS Graduate: ALS Certificate
Post Graduates Studies Category [ ] If Solo Parent: Photocopy of Solo Parent ID
[ ] Endorsement Letter from Barangay and City Council (if applicable)
 College and/or Masteral Degree graduates who will enroll
[ ] Endorsement Letter from SSDD / HCDRD / PESO / Office of the
in Higher Education Institutions with level III/IV accredited
Secretary to the Mayor (if applicable)
programs by the Commission on Higher Education
Specialized Courses Category Specialized Courses Category
 Graduates of Quezon City Public/Private Senior High Schools [ ] Recommendation letter from College Dean
enrolled in any of the specialized courses identified by the City [ ] Letter of Intent addressed to the Mayor
Senior High School Category
Post Graduates Studies Category
 Overall Top Three (3) Grade 10 completers from Quezon City
Public Secondary School [ ] Transcript of Record (TOR)
 Grade 10 completers from Quezon City Public Secondary [ ] Permit to Study
School who received national or international recognition in [ ] Letter of Intent addressed to the Mayor
non-academic endeavors duly recognized by the Department [ ] Certificate of Employment
of Education and/or the Quezon City local government [ ] Company ID
[ ] If Quezon City Government Employees: CSC Appointment Record
and Service Record
[ ] If Non-Quezon City Government Employees: Recommendation from
Head Agency and Appointment Record from Agency

For SYDP Staff Only

Received and Checked by: Interviewed by: Encoded By:

Scholarship Coordinator Scholarship Coordinator Scholarship Coordinator

Date & Time:___________________________ Date & Time:___________________________ Date & Time:___________________________

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