SMART Application Form

2023 version (NOT FOR SALE) ANNEX 1

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

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)

3. Place of Birth
10. Present Address
4. Sex ▓ Male ▓ Female

5. Civil Status

6. Citizenship 11. Name of School

7. Mobile Number 12. School Address

8. E-mail Address 13. Degree Program

PERSONAL INFORMATION

Father: ( ) Living ( )Deceased Mother: ( ) Living ( ) Deceased Legal Guardian

14. Name

15. Address

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
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.

(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