SIKAP PT: FORM B

CERTIFICATE OF ELIGIBILITY AND UNDERTAKING

Application for the Part-Time Study under SIKAP Grant

I, <<FullName>>, Filipino, <<Age>>, with permanent address at <<Complete Address>>,

after being sworn in accordance with law, hereby depose and state that:

1. I am applying for the Part-Time Study under the Scholarships for Staff and
Instructors’ Knowledge Advancement Program (SIKAP) Grant;
2. I am employed as a Teaching or Non-Teaching Personnel in a Higher Education
Institution (HEI), at the time of application; (accomplish table, as applicable)

Type Institution/s of Rank1 Employment Length of

(Check all that apply) Employment Status2 Service
(e.g. __ Years and __
Months)

❏ Employed 1.

Choose one:
❏ Single
Employment 2. (Add more rows if
❏ Multiple necessary)
Employment

❏ Self-
Employed

❏ Others

3. I am admitted or will enroll in an eligible graduate degree program offered by

designated Delivering Higher Education Institutions (DHEIs) which is/are:

(check applicable box)

☐ Autonomous/Deregulated Institutions;
☐ State Universities and Colleges (SUC) designated as Level III and above;
☐ Center of Excellence (COE) or Center of Development (COD);
☐ A program accredited as or whose equivalent undergraduate program is a
accredited as Program Level III or above; OR
☐ Mindanao State University (MSU) and its constituent units or the University of
the Philippines (UP) and its constituent units.

1 Professor, Associate Professor, Instructor, Lecturer, Guest Lecturer, Dean, Director, Registrar etc
2 Regular / Plantilla, Probationary / Temporary, Contractual / Contract of Service, Separated /
Unemployed

SIKAP Statement of Eligibility and Undertaking || as of 11 Oct 2021

SIKAP PT: FORM B

4. IF I am qualified under No. 2, letters a, b, and c of the Eligibility Criteria of the Part-
Time Study under the SIKAP Grant, I shall submit the proposed thesis/dissertation
that is aligned with the research and development agenda of either the SHEI and/or
DHEI as attested by the HEI President or its equivalent;
5. I shall secure a permit to study from the SHEI President or its equivalent and duly
endorsed by the Faculty and Staff Development Committee or its equivalent;
6. I am physically fit and mentally prepared to undertake and complete graduate work
as supported by a medical certificate; and
7. IF Full-time Faculty or HEI Personnel with Plantilla/Tenured/Regular items, I am not
more than 50 years old and I am of age that will allow me sufficient time to render
and complete return service obligation after obtaining my graduate degree and impart
my acquired degree to the higher education sector.
8. I shall disclose to the Commission if I have a relationship, up to the fourth (4th)
degree of consanguinity or affinity, with any CHED employee in the CHED Regional
Office (CHED RO) where the application is being processed3;
9. I am not holding a degree in the same degree level being applied for (i.e. applicants
applying for scholarship to pursue a doctorate degree, must not already possess a
doctorate degree);
10. I am not enrolled in more than one graduate program;
11. IF already admitted to a graduate program, I do not have failing grades, dropped
courses, have not shifted/changed the program of study, or on extension or beyond
the regular study plan;
12. I am cognizant, willing, and accepting of this commitment, and the various terms and
conditions of this grant as stipulated in the Part-Time Study under the SIKAP Grant
and all relevant CMOs and shall comply with the same, and
13. I fully understand the consequences of not giving correct and truthful data and I am
aware that non-disclosure of material information as required by Part-Time Study
under the SIKAP Grant will put me under the pain of perjury by executing this
document.

WHEREFORE, in order to attest to the truth of the foregoing, I hereby affix my signature to
this Certification this ___ day of (Month), 2021 in (City/Municipality).

___________________________

Signature over printed name

SUBSCRIBED AND SWORN to before me, this __ day of ___ 2021 at _______, Philippines.

<<NOTARY>>

3 Based on the Administrative Code of 1987, Executive Order No. 292 and SC Memorandum Circular No. 21, s.
2004

SIKAP Statement of Eligibility and Undertaking || as of 11 Oct 2021