University of the Philippines College of Engineering Melchor Hall, Diliman, Quezon City 1101 Tel/Fax: (+632 981 8500 ext 3152

Undergraduate Scholarships and Study Grants

APPLICATION FORM INSTRUCTIONS: Accomplish this form and submit to the Office of the Associate Dean for Student Affairs, UP College of Engineering. Attach with this form the following: 1) a letter of endorsement from your department chairperson/institute director and 2) an SDC clearance. Please see announcements from the Committee on Scholarships of the UP College of Engineering for the deadline of the submission.

Applicant Name: Student Number: Date and Place of Birth: Citizenship: Current Address: Home Address: Telephone/Fax/E-mail: Parent/Guardian Name: Telephone/E-mail: Address:

1. Name of Scholarship(s)/Study Grant(s) Applied for and Desired Semester/Year of Award:

(May be left blank. The committee will endorse/nominate you for the first available scholarship slot where you qualify.)

2. Year Entered the University: Current Year Classification:

3. College Degree Sought:

4. Have you ever incurred a grade of “4” or “5” in the past two semesters and last midyear if enrolled? (If yes, list the subjects, grades and semesters incurred.)

5. Did you avail of the STS? (If yes, what tuition fee discount level are you in?)

6. Estimated Gross Family Income of Parents/Guardian:

ID PHOTO

7. Are you receiving any scholarship/grant/assistance? _______ If yes, kindly provide the following details: a. Name of the funding agency: b. Benefits: c. Duration: d. Does the funding agency allow you to have other scholarships/grants/assistance? _____

8. Have you been guilty of participating in any violent incident, whether on campus or off-campus? (If yes, please explain under what circumstances.)

9. Have you been subjected to any disciplinary action involving a penalty of at least five (5) days suspension, or found guilty of a more serious offense? (If yes, please explain.)

10. Family Background

Name Relationship Age Marital Status

Living with you? (Yes/No)

Occupation

11. Describe briefly why you should be awarded the scholarship/grant applied for?

I declare under penalties of perjury that this application has been accomplished in good faith, verified by me and to the best of my knowledge and belief, is true. Signature over Printed Name Date SA-Form rev 7Jul15-NBD