SMART Application Form
ANNEX 1
2023 version (NOT FOR SALE)
Office of the President of the Philippines
COMMISSION ON HIGHER EDUCATION
2X2
ID PICTURE
STUDENT MONETARY ASSISTANCE FOR RECOVERY AND TRANSITION (SMART)
APPLICATION FORM
Instructions: Read General and Documentary Requirements. Fill in all the required information. Do not leave an item blank. If item is not applicable, indicate "N/A".
PERSONAL INFORMATION
DITCHE NORLEY CHANCE MARCELO N/A
1. Name
(Last Name) Maiden Name
(First Name) (Middle Name)
put extension, if any: i.e. Jr., III (for Married Women)
9. Permanent Address
2. Date of Birth (mm/dd/yy) 06/29/1999 317 TALAMPAS, BUSTOS, BULACAN
3. Place of Birth BULACAN
10. Present Address
4. Sex Male Female 317 TALAMPAS, BUSTOS, BULACAN
5. Civil Status SINGLE
6. Citizenship FILIPINO 11. Name of School NATIONAL UNIVERSITY - MANILA
7. Mobile Number 0929 794 0816 12. School Address 551 M. F JHOCSON ST. SAMPALOC, MANILA
8. E-mail Address
[email protected] 13. Degree Program BS in MECHANICAL ENGINEERING
PERSONAL INFORMATION
Father: ( ) Living ( )Deceased Mother: ( ) Living ( ) Deceased Legal Guardian
14. Name ERNESTO P. DITCHE NORA M. DITCHE
15. Address 317 TALAMPAS, BUSTOS, BULACAN
16. Occupation
17. Name of Employer
18. Employer Address
19. Total Parents Taxable Income
20. Is your family a beneficiary of the DSWD's Pantawid Pamilyang Pilipino Program (4Ps)? ( ) Yes ( ) No 21. No. of Siblings in the family N/A
22. Are you enjoying other sources of ( ) Yes or ( ) No Type Grantee Institution/Agency
educational/financial assistance?
If yes, please specify: 1. ______________________ _____________________________________________
___________________
2._______________________ _____________________________________________
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.
Norley Chance M. Ditche 10/02/2023
(Signature over Printed Name of Applicant) Date Accomplished
Note: Fully accomplished form to be submitted to CHED OSDS
DO NOT FILL-OUT THIS PORTION (FOR CHED USE ONLY)
Belongs to: (any of the following groups) Documents Attached:
dependent of solo parent 1. Academic
senior citizens ( ) Certified True Copy (CTC) of Certificate of Registration/Enrolment (CORs/COEs)
persons with disabilities please specify type of disability______________________
2. Financial
indigenous and ethnic peoples please specify membership _________________________
( ) ITR ( ) Tax Exemption ( ) Certifcate of Indigency ( ) Case Study Report
3. Photocopy of School ID Card or any governmenrt issued ID
Evaluated/Processed by:
Name and Signature of CHED Evaluator Date
