XAVIER UNIVERSITY –ATENEO DE CAGAYAN

ADMISSIONS AND AID OFFICE

Email aao@xu.edu.ph tel # (088) 853-9800 local 9157

XAVIER ATENEO PRESIDENT’S SCHOLARSHIP

(Please submit 2 copies of Scholarship Application Form)
Dear Applicant,

The Xavier Ateneo President’s Scholarship is awarded to Incoming Freshmen based on the merits of High School
academic performance, general scholastic aptitude in the XU Entrance Exam.
Please submit this duly filled-up application form in 2 copies on or before January 30, 2018 together with ALL of the
following required documents: (INCOMPLETE DOCUMENTS AND LATE SUBMISSION WILL NOT BE ACCEPTED.)
1. Printed result of the XU Entrance Exam
2. Photocopy of Secondary Student’s Permanent Record (Form 137-A – complete up to the last grading period) certified
correct by the Principal.
3. Clear photocopy of Parent’s latest Income Tax Return or where not applicable, a statement from BIR of tax
exemption.
4. Two signed and sealed scholarship recommendations (use downloadable form)

*Information herein disclosed will be treated confidentially. Thank you.

(DO NOT FILL THIS BOX)

CSAT/XU-CEM/OLSAT
1 x 1 Picture
GSA: _____

Name : _______________________________________________ Course Choice: __________________________

Last First Middle
Religion: _______________ Contact No. : _________________ Email add : __________________________
Gender: _______________ Date of Birth: _________________ Place of Birth : __________________________
Home Address: ______________________________________________ Tribal Group: _________________________
(Please use back page if space provided is not enough.)
1. EDUCATION:
Name and Location of School Year Attended Scholastic Honors Received
Elementary:
High School:
2. EXTRA CURRICULAR ACTIVITIES AND ORGANIZATIONAL AFFILIATIONS:

Organizational Affiliation and Community Involvements: Position Held Date

3. DIALECTS/LANGUAGES FLUENTLY SPOKEN: ___________________________________________________________

4. FAMILY BACKGROUND
Age Highest
Name Educational Status* Occupation Company Name
Attainment and Position Held
Father:
Mother:
Siblings:
1.
2.
3.
4.
_______

*For parents, state if (1) living together For siblings, state if (1) single
(2) separated (2) married
(3) deceased (3) deceased
(4) widow/widower (4) widow/widower

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5. SOURCES OF FAMILY INCOME: Salary ______________ Business _________ Fishing ________________
Farming ______________ Rental _________ Others ________________

6. TOTAL FAMILY GROSS INCOME: _____________________

7. SCHOLARSHIP:
a) Have you applied for any scholarship? _________
If yes, which? _____________________________ Where? ____________________________________

b) Have you accepted any scholarship? __________

If yes, which? _____________________________ Where? ____________________________________

Essay. Please be concise, limit your essay within the space provided.

8. Describe yourself briefly. What are your goals and dreams in life? Why do you want to study in Xavier University
and how can this scholarship (if awarded) shape your future?

We hereby certify that all the information given here is true and correct, and you are hereby authorized to verify the
same through an official inquiry if needed.

We understand that misinterpretation and withholding of information requested in the application form will be
sufficient reason for disapproval or cancellation of the grant.

Student’s signature: ____________________________ Date : __________________________________

Father’s signature : ____________________________ Mother’s signature: ______________________

 TEL. NO. (088) 853-9800 local 9157 Email aao@xu.edu.ph Website: www.xu.edu.ph

Applicant’s Name: __________________________________________________________________________

LAST NAME FIRST NAME MIDDLE NAME

Name of School: __________________________________________________________________________

School Address: __________________________________________________________________________

School Principal: __________________________________________________________________________

Residential Address: ___________________________________________________________________________

TO THE APPLICANT: Write your name and address above. Choose two persons who know you well and have held
positions of authority over you in your present school; e.g., your subject teacher, adviser, or principal. Give a copy of this
form to each of these two persons. Provide each of them with an envelope.

Ranking - as of First Semester of Senior

year
a. Number of students in class or section:____
Rank (Kindly check)
Top 10:_________ Upper Third:______
Middle Third:______ Lower Third: ______

b. Total number of graduating students:_____

Rank (Kindly check)
Top 10:____________Upper Third: ______
Middle Third:_______ Lower Third:______