Revised July 11, 2023. This form is NOT FOR SALE.
Republic of the Philippines
PROVINCE OF NEGROS OCCIDENTAL
NEGROS OCCIDENTAL SCHOLARSHIP PROGRAM Recent
Passport Size
Photo
APPLICATION FORM
Size: 4.5cmx3.5cm
Instructions: Fill out all required information using ballpen only . Do NOT leave an item blank. STRICTLY NO SELFIE.
If item is not applicable, indicate "N/A". Write legibly and in ALL CAPITAL LETTERS .
SCHOLARSHIP CATEGORY APPLIED FOR: (Please check one.)
Pagkaon District Education Scholarship (DES) Indigenous People (IP) Midwifery
Pagkaon - DCS Degree Completion Scholarship (DCS) NOPMANS - Medicine DCS-OFW
Pagkaon FoodTech Persons with Disability (PWD) NOPMANS - Nursing Children of Non-Returning OFW
Best of Negros Scholarship (CONROFW)
*Name:
(last) (first) (Ext. Name, i.e. Jr/Sr., if any) (full middle)
*Home Address:
(Pls. include street, purok, hacienda, sitio, zone) (barangay) (city or municipality)
*Civil Status: *Religion: *Citizenship:
*Date of Birth: *Place of Birth: *Age: *Sex: Male Female
(month/dd/yyyy) (e.g. June 17, 1970) (city or municipality)
*Email Add: *Tel. No. *Mobile No.
*EDUCATIONAL BACKGROUND
LEVEL SCHOOL ADDRESS YEAR GRADUATED ACADEMIC HONORS RECEIVED
Elementary
Junior High School
(Grade 10)
Senior High School
(Grade 12)
College Current Year Level:
Course
Grade 12 Out of School
*PREFERENCE (To be filled out by incoming college students only.) Youth
1st 2nd 3rd 4th 5th
COURSE SCHOOL
1st priority
2nd priority
*FAMILY BACKGROUND
Father: Living Deceased Age: Mother: Living Deceased Age:
Name: Name:
Address: Address:
Occupation: Occupation:
Company: Company:
Monthly Income: ₱ Monthly Income: ₱
Highest Educational Attainment: Elem High School College Post Grad Highest Educational Attainment: Elem High School College Post Grad
Name of Siblings Age Sex Relation Highest Educational Attainment Occupation Monthly Income
1 ₱
2 ₱
3 ₱
4 ₱
5 ₱
No. of siblings in the family: (Use separate sheet if more than 5.)
For Children of Non-Returning OFW or DCS-OFW applicants only:
Previous occupation abroad: Country: Last date of employment:
*DECLARATION
I. Have you applied to any scholarship grant or program other than NOSP? Yes No If yes, please specify:
e.g. DOST, CHED, SRA, etc.
II. I hereby certify that all information given are true to the best of my knowledge.
Any misinformation or misdeclaration I have made will be a ground for my disqualification for admission to the program.
CONFORME:
Signature or Thumbmark over Printed Name of Parent/Guardian Signature over Printed Name of Applicant Date Accomplished
(month/dd/yyyy)
*Contact No. of Parent/Guardian:
DO NOT FILL OUT THIS PART.
(For NOSP Coordinators only.)
Applicant is qualified for: Required documents submitted:
DES Birth Certificate (Photocopy) For Senior HS graduates - Grade 12 Report Card REMARKS:
Pagkaon Transcript of Record (Photocopy) For Senior HS applicants - Grade 11 Report Card
IP Income Tax Return (ITR) of Parent/Guardian Cert. from Punong Barangay (back page)
DCS Certificate of Tax Exemption Cert. from Principal/College Dean (back page)
CONROFW Passport Photo Cert. from Parent/Guardian (back page)
Nursing Genealogy Form (for IP applicants only) Photocopy of Passport Biopage with latest arrival stamp (for
PWD ID (for PWD applicants only) CONROFW and DCS-OFW applicants only)
Medicine
PWD NMAT Results (for Medicine applicants only) Certificate of Appointment (for BHW applicants of Midwifery)
Dualtech Narrative Report (for DCS and Midwifery Applicants only)
Midwifery
Evaluated/Assessed by:
NOSP Coordinator Date
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