PED – 001–0
Republic of the Philippines
PROVINCE OF ILOCOS NORTE
Laoag City 2900
2x2 ID picture
PROVINCIAL EDUCATION OFFICE
“ACADEMIC SCHOLARSHIP”
PERSONAL PROFILE FORM
NAME:____________________________________________________________________________
FIRSTNAME
SURNAME
MIDDLE NAME
DATE OF BIRTH: _________________________ AGE: _____SEX: ______ CIVIL STATUS: __________
SCHOOL: _________________________________________ COLLEGE: _________________________
COURSE:________________________________ MAJOR: ___________________ YEAR LEVEL: _____
GEN. WEIGHTED AVERAGE:_________ EXPECTED YEAR OF GRADUATION: _____________________
CURRENT ADDRESS: _________________________________________________________________
BARANGAY
STREET NO.
CITY/ MUNICIPALITY
PROVINCE
PERMANENT ADDRESS: ______________________________________________________________
BARANGAY
STREET NO.
CITY/ MUNICIPALITY
PROVINCE
CONTACT NUMBER: ______________________ALTERNATE CONTACT NUMBER: ____________________
PRIMARY EMAIL ADDRESS: ________________ALTERNATE EMAIL ADDRESS:____________________
MONTHLY FAMILY INCOME:Php________________
SPECIAL SKILLS/ HOBBIES:_____________________________________________________________
EDUCATIONAL BACKGROUND:
LEVEL
ELEMENTARY
JUNIOR HIGH SCHOOL
NAME OF SCHOOL
TRACK/STRAND
YEAR GRADUATED
SENIOR HIGH SCHOOL
AGE
ADDRESS
CONTACT NUMBER
OCCUPATION
AGE
ADDRESS
CONTACT NUMBER
OCCUPATION
NAME OF FATHER:
NAME OF MOTHER:
NAME OF SIBLINGS
1.
2.
3.
4.
5.
6.
WRITTEN INTERVIEW:
1. Why do you want to avail the “Academic Scholarship”?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. Do you have previous scholarship grants? YES ____ NO ____
(If yes, what kind scholarship, please specify)
_____________________________________________________________________________
_____________________________________________________________________________
3.
3. Did you apply for scholarships other than Academic Scholarship? YES___ NO____
(If yes, what kind scholarship, please specify)
_____________________________________________________________________________
_____________________________________________________________________________
4. Do you have some Leadership track records?
_____________________________________________________________________________
_____________________________________________________________________________
5. Are you willing to render community service? _______________
6. How do you balance your time for community service and academic activities?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_______________________________________
SIGNATURE OVER PRINTED NAME
_______________________________
DATE ACCOMPLISHED
DOCUMENTARY REQUIREMENT CHECKLIST
(to be accomplished by the PED staff)
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Application letter addressed to Hon. Governor
Accomplished Personal Profile Form
Original Certificate of Grades/ Photocopy of Graded Class cards
Photocopy of Good Moral Character from School/College
Photocopy of PSA Birth Certificate
Original copy of Barangay Clearance
Original copy of Certificate of Indigency/Low Income (Municipal/City Social Welfare)
RECEIVED BY:
___________________________
DATE RECEIVED:
___________________________
2nd floor Centennial Arena, 2900 Laoag City | Telephone No.: 600-0636
Facebook Page: PGIN Education Office| E-mail Address: educationdept_pgin@yahoo.com.ph| S.Y. 2022-2023