APPLICATION FORM FOR PART-TIME STUDY

Application
Number

Instructions: (1) Please write in PRINT; (2) Use a check mark ( ✓) to answer the appropriate box corresponding to your answer.

PERSONAL INFORMATION

Last Name First Name Middle Name Extension Name

Birthdate (mm/dd/yyyy) Age (yy/mm) Email Address

Permanent Address

Current Address

Mobile Number Phone Number Citizenship

Highest Educational Attainment Bachelor’s Degree Master’s Degree Doctorate Degree

ELIGIBILITY DETAILS

Are you presently admitted / YES Degree Level Masters Mode of Implementation Individual Model
enrolled in a graduate program at Applying for
a Philippine Higher Education NO Doctorate DHEI Model
Institution?

If admitted, indicate degree HEI: Degree Program:

program and Higher Education _______________________________________________ ______________________________________________________________
Institution

If enrolled in current term, HEI: Degree Program:

indicate degree program and _______________________________________________ ______________________________________________________________
Higher Education Institution

Total Number of If enrolled in current term, Type of Teaching Teaching Discipline /

Units taken Start Month of Term: ________ Personnel in Discipline of Practice or
_____________ End Month of Term: _________ HEI Non-Teaching Work (see PSCED code) __________________

Are you related to any CHED employee by YES If Yes, give details (Name and Position):
consanguinity or affinity, up to the fourth degree, to
the approving or recommending authority, where NO
the application is being processed? __________________________________________________________

Are you currently holding a full-time employment in YES If Yes, indicate the Name of the Government Agency or Private Company
any government agency or private company, which
are not HEIs (e.g. State and Local Universities and NO
Colleges, Private HEIs, etc)? __________________________________________________________
EMPLOYMENT DETAILS (at the time of employment)

HEI of Employment Address

(Do not abbreviate) _____________________________________________ _____________________________________

College / Office / Department of Work Assignment ______________________________ Number of Years in the HEI _____________

Employment Status I am still employed in this I am separated / no longer Type of Teaching

(at the time of institution employed in this institution Personnel
application) Non-Teaching

If employed, indicate type of Regular / Plantilla Probationary / Temporary Contractual / Contract of Service
employment

If separated/unemployed, With YES Tenure Permanent

indicate last date of employment _____________ Administrative
Load NO Non-Permanent

GOVERNMENT FUNDED SCHOLARSHIP OR GRANTS

Have you ever received a scholarship or grant or YES NO Have you ever been approved as a grantee or part of the
training from any government agency? following CHED Grants / Project? (check all that apply)

If Yes, indicate name of agency/office and name of grant SGS-L CMO 51

SGS-A DARE TO
Agency: ___________________________________________________________
RECPE SALIKHA
Grant: ____________________________________________________________ IDIG Professional Advancement

Return Service Period (mm/yyyy - mm/yyyy) : _____________________________ CPE FDP

ICPE Others __________________
__________________

RESEARCH PUBLICATION

Publication Publication Date Published

Title Type

Authorship Name of Journal, Association

(Sole, Lead, Co-Author)
or Corporation

Short Description of Work:

Publication Publication Date Published

Title/Project Type

Authorship Name of Journal, Association

(Sole, Lead, Co-Author)
or Corporation

Short Description of Work:

ACADEMIC PAPER PRESENTATIONS

Title of Paper Name of Conference

Conference Type of Conference Date of

Venue (Local or International) Presentation

Short Description of Work:

Title of Paper Name of Conference

Conference Type of Conference Date of

Venue (Local or International) Presentation

Short Description of Work:

CONSULTANCY WORK / SOCIAL WORK AND/OR COMMUNITY EXTENSION

Institutional Affiliation

Position Period Covered Work

(mm/yyyy - mm/yyyy) Output

Roles/Responsibilities

Institutional Affiliation

Position Period Covered Work

(mm/yyyy - mm/yyyy) Output

Roles/Responsibilities

TRAINING PROGRAMS ATTENDED

Title of Training Number of Hours Period Covered

Conducted by: Training Venue

Title of Training Number of Hours Period Covered

Conducted by: Training Venue

POTENTIAL OUTCOMES

Statement of Purpose

Write about a research

project that you conducted.
Why was this of interest to
you? How did this
contribute to the discipline?

Write about a research

problem that you intend to
study or explore. How will
this contribute to the
discipline?
ELIGIBILITY CERTIFICATION

By signing this certification, I certify to the following:

1. I am a Filipino citizen;
2. I am holding any of the following employment status:
a. Full-time Faculty or HEI Personnel with plantilla/tenured items with minimum performance rating of
“Very Satisfactory” or its equivalent in the past three (3) years of continuous service to the sending
higher education institution (SHEI) at the time of application;
b. Full-time Faculty or HEI Personnel with temporary or probationary appointments with minimum
performance rating of “Very Satisfactory” or its equivalent for at least one (1) year in the SHEI;
c. Contractual or Contract of Service HEI Personnel with Full-Time Equivalent Teaching Load / Work
Load with existing contract with the SHEI at the time of the application and have continuously
served the SHEI as full-time contractual/contract of service employee in the past 2 years with a
minimum performance rating of “Very Satisfactory” or its equivalent at the time of application; or
d. Part-time Contractual or Contract of Service Faculty with an existing contract with the SHEI at the
time of the application and have continuously served the SHEI as full-time/part-time faculty for 3
cumulative academic years (AY) with a minimum performance rating/Student Evaluation of
Teachers (SET) of “Very Satisfactory” or equivalent.
3. I am admitted or will enroll in an eligible graduate degree program offered by designated Delivering Higher
Education Institutions, which are:
a. Autonomous/Deregulated Institutions;
b. State Universities and Colleges (SUC) designated as Level III and above;
c. Center of Excellence (COE) or Center of Development (COD);
d. A program accredited as or whose equivalent undergraduate program is a accredited as Program
Level III or above; or
e. Mindanao State University (MSU) and its constituent units or the University of the Philippines (UP)
and its constituent units.
4. If my employment status is covered under Section 2.1.2.1, 2.1.2.2, and 2.1.2.3 of CMO No. 28, s. 2021, 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;
7. If my employment status is covered under Section 2.1.2.1 and 2.1.2.2 of CMO No. 28, s. 2021 (Full-time
Faculty or HEI Personnel with plantilla/tenured or temporary/probationary appointments), I am of age that is
not more than 50 years old to 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 currently do not hold a degree in the degree level being pursued (i.e. applicants for a scholarship for
doctorate degree, must not already possess a doctorate degree, unless otherwise allowed through the
proper exemptions);
9. I am not enjoying any other government-funded scholarship or grant at the time of application; and
10. I shall disclose to the Commission if I have, up to the fourth (4th) degree of consanguinity or affinity, to any
CHED employee in the CHED Regional Office (CHED RO) where the application is being processed.

________________________________ ________________________________
Signature above Printed Name Date Signed
OMNIBUS CERTIFICATION

This is to certify that by signing this document:

● All information I have provided in this form is complete, true and correct to the best of my knowledge.

● I fully understand and accept the legal consequences and take full accountability of giving incorrect,
untruthful, non-disclosure and/or misleading information to CHED.

● I certify that the supporting documentary submissions are not altered or modified electronically or otherwise.
The Commission reserves the right to hold processing of applications which may be suspected to have been
altered or modified, subject to further validation;

● I understand that all submitted application documents including its supporting documents shall be
considered as property of the Commission and shall no longer be returned to the applicant notwithstanding
the result of the application;

● I hereby give my consent for the Commission to collect, record, retrieve, consolidate and use information I
have voluntarily provided concerning my scholarship as provided under the “Revised Guidelines for the
Scholarships for Staff and Instructors’ Knowledge Advancement Program (SIKAP) Grant for Part-Time
Studyt”.

● I am cognizant, willing, and accepting of this commitment, and the various terms and conditions of this grant
as stipulated in CHED Memorandum Order (CMO) No. 28 s. 2021 and all relevant CMOs issued and to be
issued, and shall comply with the same;

________________________________ ________________________________
Signature above Printed Name Date Signed