Name:

Grade Level:
Brgy:
Status:
General Average:

PERSONAL INFORMATION
Last Name: Given Name: Middle Name: Sex: Age:

Date of Birth: Place of Birth: Civil Status: Religion:

Unit No. / House No. : Street / Subdivision / Village Name: Barangay:

Mobile No.: Email Address: Working Student:

__Yes __No

CURRENT SCHOOL INFORMATION

Name of School: School Type: Academic Level:

Type of ID: ID Number: LR Number:

FAMILY INFORMATION
Relationship Name: (Write “Deceased” as applicable ) Occupation Monthly Income

Father

Mother

Guardian

Combined Monthly Income

EDUCATIONAL BACKGROUND (For NEW Applicants ONLY)

Name of School Inclusive Years Honors and Awards

Elementary

Junior High School

Senior High School

College Program or Course:

VOTING RECORD : Registered ___Yes ___No

Mode of Receipt of previous Scholar Allowance (For RENEWAL Applicants ONLY)

Paymaya LandBank ____ Pagador (Payroll)
__ Successful / Claimed __ With Actual Cash Card
__ Unsuccessful / Unclaimed __ With Account No. only; No physical cashcard

ACCEPTANCE OF TERMS
We affirm that the facts herein provided are true and correct as of the date hereof. We hereby authorize the Pasig City
Scholars Office and its authorized representatives to verify the information submitted. We understand that if awarded the
benefits under the PCS, any false statement, omissions, or misrepresentation made in this application form may result in the
immediate withdrawal of the scholarship grant.

______________________________________ ____________________________________________
Signature over printed name of Applicant Signature over printed name of Parent/ Guardian