PSP Form No.

REPUBLIC OF THE
PHILIPPINES
PROVINCE OF
PANGASINAN
Lingayen

PSP ACADEMIC SCHOLARSHIP APPLICATION FORM

PHINMA – University of Pangasinan at

I wish to apply for college scholarship assistance and enroll at _____________________________________________
(Name of school and address) for the course
Dagupan, Pangasinan, Philippines
_____________________________________________________________ effective Academic Year 2022-2023.

In support to my application, attached are the following documents:

1. Senior High School Fourth (Final) Grading Report Card with General Weighted Average (GWA) of 88% or higher
(Certified Photocopy by the Class Adviser or authorized school representative)
2. Social Case Study Report from the Municipal or City Social Welfare & Development Office (Original Copy)
3. Certificate of Scholarship Eligibility (PSP Form No. 2)
4. Individual Information Sheet with recent picture. (PSP Form No. 3)

I hereby authorize the Provincial Scholarship Program Management, Evaluation and Excellence Committee
(PSPMEEC) or its duly authorized representative, to investigate all facts concerning my skills, habits, character, background and
such other information pertinent to my qualifications.

I understand that any misrepresentation, falsification or any omission of such fact, of whatever nature, required by
this
application shall be considered a sufficient cause for denial of my application or termination of my scholarship privileges if
already granted.

If accepted, I promise to abide by the rules and regulations, as embodied in the provisions of the Guidelines for PSP
for Academically Highly Competent College Students, which I have read and fully understood.

Gleyan Meg P. Ferrer

___________________________________________
(Applicant’s Signature over Printed Name)
___________________________________________
Saint Charles Academy, Malong St. 2420 San Carlos City, Philippines
(Name and Address of School Graduated)

---------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Note: PSP Academic Scholarship Application Form may be reproduced. Page 1 of 4 (May 2022)
PSP Form No. 2
CERTIFICATE OF SCHOLARSHIP ELIGIBILITY

Gleyan Meg P. Ferrer

This is to certify that ___________________________________________________________________ is a graduate of
(Name of applicant)
Saint Charles Academy, Malong St. 2420 San Carlos City, Philippines
_________________________________________________________________________ May 06, 2022
on________________________________
(Name of school and address) (Date of graduation)
under the ________________________________________________________________
Accountancy, Business and Management (ABM) and met all the requirements for graduation.
(Academic Track/ Strand)

This is to certify further that he/she is of good moral character. He/ She is a recipient of the following academic and nonacademic
awards and citations:

(Please check box)

ACADEMIC HONORS
With Highest Honors With High Honors With Honors

EXTRA-CURRICULAR ACTIVITIES
Date Award Received (Champion, Level
Title of Competition
(mm/dd/yy) Runner-Up etc.) (Municipal, Provincial, National, etc.)

TOTAL NO. OF GRADUATING SENIOR HIGH SCHOOL STUDENTS: _________

ATTESTED:

Mr. Richard B. Quijano

_________________________________
(Signature over Printed Name)
Class Adviser or Guidance Counsellor of Applicant

May 17, 2022

________________________
Date

Note: PSP Academic Scholarship Application Form may be reproduced. Page 2 of 4 (May 2022)
PSP Form No. 3

INDIVIDUAL INFORMATION RECORD

Gleyan Meg P. Ferrer

Name: ________________________________________________________ 18
Age: _________________ Female
Gender: ___________

Directions: Give what is being called for as accurately and honestly as you can. Any misrepresentation may disqualify you for the
Scholarship. PART III should be accomplished with the help of your parents or guardians.

PART I
Virgen Milagrosa Medical Center, 34 Dr. Martin P. Posadas Avenue,
01/27/04
1. Date of Birth (mm/dd/year)_________________________ San Carlos City, 2420 Pangasinan
Place of Birth________________________________________
M.Soriano Street, San Carlos City, Pangasinan
2. Present Address ____________________________________________________________________________________
09083677076
3. Contact Number/s: __________________________________________Email ____________________________________
gleyanmegf@gmail.com
4. No. of years of stay in the present address________________________________________________________________
18 years

PART II

Longino D. Ferrer Teaching

1. Father’s Name _____________________________________ Occupation _______________________________________
Gross Income per month ______________________________________________________________________________
2. Mother’s Name____________________________________
Milanie P. Ferrer Teaching
Occupation ________________________________________
Gross Income per month ______________________________________________________________________________
3. Guardian’s Name (if applicable)__________________________________ Occupation _____________________________
Gross Income per month ________________________________________________________________________
4. What do you like to be someday? _______________________________________________________________________
I want to become an Flight Attendant
My father wants me to become an Flight Attendant.
What does your father like you to be? ____________________________________________________________________
What does your mother like you to be? ___________________________________________________________________
My mother wants me to become an Flight Attendant also.
What do your teachers like you to be? ____________________________________________________________________
My teachers want me to become an Flight Attendant.
What do your friends like you to be? _____________________________________________________________________
My friends want me to become an Flight Attendant
I have three sister
5. How many brothers and sisters do you have? ______________________________________________________________
also.
How many are studying? ______________________________________________________________________________
three
Elementary: one ( 1) Junior High School: two (2_)_Senior High School __________ College: _____one (1)___________
6. What other means of income does your family have aside from those mentioned in questions 1 and 2?
Please list them below:
Other Sources of Income Monthly Income
None
________________________ _______________________
None
None
________________________ None
_______________________
None
________________________ None
_______________________

PART III

In at least 50 words, state your reason for applying for in this college scholarship.

My parents strive and work hard for my future, so I deserve a scholarship. I also promise to myself
____________________________________________________________________________________________________

that I will work hard in school to honor my parents' sacrifices. I am a self-driven, dedicated student that has
____________________________________________________________________________________________________

attainable goals and dreams and wants to help society as a whole. In the end, it's less about me and more
____________________________________________________________________________________________________

about other people. Your scholarship will help me accomplish my goals.

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Note: PSP Academic Scholarship Application Form may be reproduced. Page 3 of 4 (May 2022)
 ____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
(Please use the back sheet if space is not enough.)

I HEREBY CERTIFY that the answers ATTESTED:

to the foregoing are true and correct.

Gleyan Meg P. Ferrer

____________________________________________ Longino D. Ferrer
___________________________________________
(Applicant’s signature above printed name) (Parent’s/Guardian’s signature above printed name)

May 17, 2022

_______________ May 17, 2022
_______________
(Date) (Date)

Note: PSP Academic Scholarship Application Form may be reproduced. Page 4 of 4 (May 2022)