OSA-SFAD Form #3

Revised October 2010

UNIVERSITY OF THE PHILIPPINES LOS BAOS

APPLICATION FORM
UNDERGRADUATE STUDENT ASSISTANTSHIP

Name: ___________________________________________

College: ________________

(Print Name & Sign above)

Student Number: ____________________________________

Classification: ______________________________________

Degree: ________________
Major: _________________

(OF/SO/JR/SR/SR- graduating/transferee)
Campus/Present Address: _________________________________________________________________
Provincial Address: ______________________________________________________________________
Contact Info: _____________________
Occupation of Mother: __________________________
Occupation of Father: ___________________________
For Old and Transfer Students:
:
: List of Subjects and Grades in the previous semester:
: __________Semester 20_____ - 20_____
Other scholarships/
:
Academic Subjects
Units
Grades
grant/award:
: _____________________
________
__________
_______________
: _____________________
________
__________
: _____________________
________
__________
Other financial
: _____________________
________
__________
Assistance/privilege : _____________________
________
__________
_________________
: _____________________
________
__________
: _____________________
________
__________
:
Total
________ Ave._________
: Non-Academic
: _____________________
________
__________
: _____________________
________
__________
----------------------------------------------------------------------------------------------------------------------Number of registered units this semester: _________ Semester 20_____ - 20 ____
Academic _________ Non- Academic _____________
STFAP Bracket
Assignment: ________

Certified Correct by:

________________________
College Secretary

----------------------------------------------------------------------------------------------------------------------------------------III. Department/Office where student will work: _________________________________________________

Immediate Supervisor (w/ signature): _____________________________________________________
Work to be accomplished_______________________________________________________________
_____________________________________________________________________
Maximum work hours per month: _______________
Rate per hour P30.00
Date of effectivity: From: Upon Approval to _______________
Account Code: STFAP

---------------------------------------------------------------------------------------------------------------------RECOMMENDED FOR APPROVAL:

BUDGET CLEARANCE:

1. _____________________________

4.

Dean/Director/Chairman

2.

ETHEL T. CABRAL
Chief, Budget Management Office

APPROVED / DISAPPROVED:
Head, Scholarships & Financial Asst. Div.
5.

3.
Director, OSA

_________
date

OSCAR B. ZAMORA
Vice-Chancellor for Instruction

REMARKS: __________________ State whether original,renewal,vice whom,etc. If transfer, state from what department and if replacing another
student, state the reason why the incumbent student was replaced viz, resigned, transferred graduated.
Note: Accomplish in five (5) copies. Return to SFAD-OSA after signature of Dean/Director

V. Schedule of Classes:
TIME
8:00 - 8:30
8:30 - 9:00
9:00 - 9:30
9:30 - 10:00
10:00 -10:30
10:30 -11:00
11:00 -11:30
11:30 -12:00
12:00 -12:30
12:30 - 1:00
1:00 - 1:30
1:30 - 2:00
2:00 - 2:30
2:30 - 3:00
3:00 - 3:30
3:30 - 4:00
4:00 - 4:30
4:30 - 5:00
Work Schedule:
TIME
8:00 - 8:30
8:30 - 9:00
9:00 - 9:30
9:30 - 10:00
10:00 -10:30
10:30 -11:00
11:00 -11:30
11:30 -12:00
12:00 -12:30
12:30 - 1:00
1:00 - 1:30
1:30 - 2:00
2:00 - 2:30
2:30 - 3:00
3:00 - 3:30
3:30 - 4:00
4:00 - 4:30
4:30 - 5:00

Monday

Tuesday

Wednesday

Thursday

Friday

Monday

Tuesday

Wednesday

Thursday

Friday

1. Why are you applying for assistantship?

______________________________________________________________________________
2. Where and when was your last assignment as Student Assistant? (indicate dept/unit,
semester/summer)
______________________________________________________________________________
3. Do you know how to type? ________
4. Are you computer literate? ________. Indicate the software/programs you are knowledgeable
with._____________________________
_____________________________________________________________________________________
To the Department /Unit Head:
It is understood that my failure to report for a continuous period of three (3) weeks without
prior notice at all to my immediate superior shall mean that I am no longer interested to render my
service/s as Student Assistant, therefore I may be replaced.

_____________________________
Signature of Applicant

_____________________________
Signature of Immediate Supervisor