Republic of the Philippines
Province of La Union
MUNICIPALITY OF AGOO
MUNICIPAL SCHOLARSHIP PROGRAM
PASSPORT SIZE
(In accordance with Municipal Ordinance No. 39-2023) ID PICTURE
APPLICATION FORM
Instructions: Please read the General and Documentary Requirements. Fill in all the required information.
No. _______________
Do not leave an item blank.If item is not applicable, indicate "N/A".
QUALIFICATIONS: REQUIREMENTS:
1. The applicant must be an incoming freshman or college student enrolled in a 1. Duly accomplished Application Form.
Commission on Higher Education (CHED) and/or Department of Education (DepEd)
accredited government or private institution carrying the normal or standard academic 2. Voter's Certification from the Commission on Election, or if not available,
load units per semester. a Certificate of Residency from the Punong Barangay stating that the applicant
is a bona-fide resident of the municipality for at least one (1) year, along
2. The applicant must belong to the poor and underprivileged students, those whose with any valid government issued ID.
gross family income does not exceed Php12,000.00 per month.
3. Certificate of Indigency or Low-Income from his/her Punong Barangay or a
3. The applicant must have a clean record and must be a Bonafide resident of Agoo. Certificate of Non-filing of Income Tax of his/her parents/guardians from the
Bureau of Internal Revenue.
4. No two (2) or more members of the same family shall be allowed to enjoy the
scholarship program at the same time, except for orphans. 4. Certificate of enrollment or his/her Enrollment/Assessment Form along
with receipts from the university or college where the applicant is enrolled with.
5. The applicant must not be a recipient of any other scholarship grants or educational
grants from any government/private institution except those academic scholarship 5. Letter of Recommendation, stating that the applicant has a General
grants such as Dean's Lister or the like by their respective schools.
Weighted Average (GWA) of 85 or above with no grade lower than 80 or its
equivalent, and a Certificate of Good Moral Character.
6. The applicant must fill out the Application Form along with all the mandatory
requirements for submission to the Municipal Scholarship Committee (MSC) through
6. Endorsement Letter from the Punong Barangay and Principal or Dean of the
the Local Youth Development Officer as head secretariat.
College or School Registrar stating that the applicant is not a recipient of any
scholarship grant.
7. The qualified applicants must undergo a panel interview conducted by the MSC.
PERSONAL INFORMATION
Name
(Last Name) (First Name) (Middle Name)
Date of Birth
(mm/dd/yy) Permanent Mailing Address
Place of Birth
Sex Male Female Zip Code
Civil Status Single School Name
Married
School Address
Citizenship School Type ( )Public ( )Private
Mobile Number Highest Grade/Year
E-mail Address Type of Disability (if applicable)
FAMILY BACKGROUND
Father: ( ) Living ( ) Deceased Mother: ( ) Living ( ) Deceased
Name Name
Address Address
Occupation Occupation
Educational Attainment
Educational Attainment
Total Parents Gross Income No. of Siblings in the family
School Intended to enroll in:
School Address:
Type of School: ( ) Public ( ) Private
Course: ____________________________________
I hereby certify that foregoing statements are true and correct. Any misinformation or witholding of information will automatically disqualify me from the Municipal Scholarship Program. I am willing to refund the
financial benefits received if such information is discovered after acceptance of the award.
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) Date
DO NOT FILL OUT THIS PORTION ( FOR MSC USE ONLY)
School Intended to Date received:
enroll in: No. _________________________
School Address: Time received:
Type of School: ( )Public ( )Private Course:
Evaluated and Processed by:
________________________ ________________
Secretariat Date
