BULACAN STATE UNIVERSITY
City of Malolos, Bulacan
OFFICE OF THE STUDENT FINANCIAL ASSISTANCE
AND SCHOLARSHIPS
Tel.# (044) 9197800 local 1086/ (044) 7906520
[email protected] A P P L I C A T I O N F O R M
PICTURE
Scholarship Category/Specification 2x2
____Semester SY 20__- 20___
Date: _________________
PERSONAL DATA
1. Name:______________________________________Age:____Course/Yr./Sec.___________
(Surname) (First Name) (Middle) Major: __________________
Student Number:_______________
Campus: ( ) Main Campus ( ) Satellite: ________________
Place of Birth ____________________________________Citizenship__________________
Date of Birth ____________________________________ Civil Status _________________
Permanent Address _______________________________Contact No.__________________
2. Father _________________________ Occupation___________Monthly Income:__________
If retired, year of retirement ____________If with pension, amount of pension_____________
3. Mother _________________________ Occupation___________Monthly Income:________
If retired, year of retirement __________If with pension, Amount_______________________
3.1 If both parents are unemployed, state reasons/s
(e.g. retired, old age, health, etc. source of livelihood) _________________________
(or contributions from other sources like relatives, etc.) ________________________
4. If self-employed, (e.g. state type of business) ____________Annual Earnings P____________
5. Guardian ____________Occupation _____________ Salary_______ Relation _____________
6. (If applicant is employed)
Occupation _________________Salary ________
7. (If applicant is married)
Name of Husband/Wife ____________ Occupation ____________Salary ____________
Name of Children/s Age
__________________________________________ _________________
__________________________________________ _________________
8. (For unmarried applicant only)
Names of Brother and Sister Age Civil Status If working, state income/If student, state year level
_________________________ ___ _________ _____________________________
_________________________ ___ _________ ______________________________
_________________________ ___ _________ ______________________________
BulSU-OP-OSFAS-01F1
Revision: 1
9. Subjects taken in the Immediate No. of Units Grade
Preceding Semester
_________________________ ___________ ____________
_________________________ ___________ ____________
_________________________ ___________ ____________
_________________________ ___________ ____________
_________________________ ___________ ____________
_________________________ ___________ ____________
_________________________ ___________ ____________
_________________________ ___________ ____________
Total No. of units ___________ GPA ____________
10. OTHER INFORMATION:
1. Are you enjoying any scholarship or financial assistance, in the University? Yes ( ) No
( ). Outside the University? Yes ( ) No ( )
If the answer is “yes” to either or both, specify nature and amount of grant or
salary:______________
2. Do your parents: (a) own real properties? Yes ( ) No ( )
If yes, specify: __________________________Market Value ______________
Others: (ex. cars, stocks, etc.) Market value: ___________________
I hereby certify that all the statements above are true and correct.
__________________________________
SIGNATURE OVER PRINTED NAME
Noted by:
MS. ELENITA P. GALVEZ OLIVER R. MARIANO, ASEAN, ENGR.,
Head, OSFAS Dean, Student Affairs and Services
Recommending Approval:
DR. EDGARDO M. SANTOS
Vice President for Academic Affairs
Approved:
DR. CECILIA N. GASCON
President
