PHILIPPINE SCIENCE HIGH SCHOOL SYSTEM
Campus: ____________________________
SCHOLARSHIP CATEGORIZATION APPLICATION FORM
(To be filled out by the student and parent/guardian)
A. STUDENT DATA
1.1 Student Name __________________________________________________________________
(Family Name) (Given Name) (Middle Name)
1.2 Home Address _________________________________________________________________
__________________________________________________ Tel. No. ___________________
1.3 What are the sources of income of the household? (please encircle all applicable items)
1 business 6 remittances from abroad
2 practice of profession (e.g. lawyer) 7 commissions
3 farms/haciendas/fishponds 8 dividends/interests/earnings from investments
4 real estate rentals 9 GSIS/SSS pension
5 salaries or wages 10 Others ______________________________
1.4 Home Ownership: (encircle numeric code)
1 Own house (fully paid)
2 Own house (mortgaged): Monthly amortization P__________________
3 Renting: Monthly rental P__________________
4 Neither owned nor rented Name of owner: _________________________________________
Relationship of owner to family _____________________________
Contributions, if any, to house owner P__________________/month
1.5 Which of the following vehicles are owned by/provided for every member of the family?
(Please fill in appropriate answer)
Number of Units Year Acquired/Model Plate No.
a. Car ________________ ________________ ________________
b. Owner-type jeep ________________ ________________ ________________
c. Passenger jeepney ________________ ________________ ________________
1.6 Real Properties Owned
Lot Area/Floor Area Location Estimated Market Value
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
_________________ ____________________________________ ____________________
PSHS-00-F-REG-10-Ver02-Rev0-02/01/20 Page 1 of 2
S T A T E M E N T S
Statement of the Applicant
I hereby certify that all the data and information which I have furnished are accurate and complete. I
understand that any willful misinformation and/or withholding of information will automatically disqualify me
from receiving the PSHS scholarship. Furthermore, if such misinformation and/or withholding of information
on my part is discovered after the scholarship has been awarded, I will reimburse all the financial benefits
received.
________________________________________
Applicant’s Signature over Printed Name
Statement of the Applicant’s Parent or Guardian
I hereby certify to the veracity and completeness of the information which my son/daughter/dependent
has furnished in this application. I further recognize that in signing this form, I share with my
son/daughter/dependent the responsibility for the veracity and completeness of the information supplied herein.
________________________________________
Parent’s/Guardian’s Signature over Printed Name
A C K N O W L E D G E M E N T
REPUBLIC OF THE PHILIPPINES )
) S.S.
BEFORE ME, a Notary Public for and in the above jurisdiction personally appeared
___________________________________________ this day of _____________________, ___, with
Community Tax Certificate No. _____________________ issued at ________________________, on
_____________________________, known to me to be the same person who executed the foregoing instrument
and acknowledged to me the same is his true act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on the date and place above stated.
NOTARY PUBLIC
Doc. No. _________________
Page No. _________________
Book No. _________________
Series of _________________
PSHS-00-F-REG-10-Ver02-Rev0-02/01/20 Page 2 of 2
