REPUBLIC OF THE PHILIPPINES PROVINCE OF LAGUNA, OFFICE OF THE GOVERNOR Provincial Capitol Compound , Santa Cruz, Laguna APPLICATION FORM ‘SCHOLARSHIP PROGRAM OF LAGUNA 2ND SEM. ALY. 2021 - 2022 TORE TILLED UP BY THE student ‘Slot No. zua00.273 Name of Student PEREZ, MARIA GELLA, M (surnamed ‘Given Name way re sex ic : ROMAN ae Female Status SINGLE Religion OMAN Date of Birth | ____2000-03:18 "place of Birth NAGCARLAN, LAGUNA ___ esr Ades eden 125 OKT Province ___LAGUNA "Municipality NAGCARLAN Harangay __TALANGAN— el No, Cel. No08753055568 Email e2318@Rmallcom Te No, (Cel No 087880555 al mgperezsi#@gmall ‘Name of Father RENATO R-PEREZ "Occupation CARPENTER tncomne0 S000 Muee’ —FLICIMAM.PEREZ oeupation SCHOOL CANTEENER IncomerMo7500 Qittuan — FHCIMAM.PEREZ Relation MOTHER ncome/Mo7500 ‘Tel No. /Cel. No cnass490689 Ansan Family GF 40000 ‘choot Graduated Address of School Year Graduated ‘CRISANTO GUYSAYKO LOPEZ JAENA ST. Elementary MEMORIAL ELEMENTARY ‘POBLACION it 2011-2012 SCHOOL, NAGCARLAN, LAGUNA, TACANGAN INTEGRATED ‘BRGY. TALANGAN Secondary NATIONAL HIGH SCHOOL —_NAGCARLAN- LAGUNA aus Senior High ATOM GRATED een oe 2017-2018 NATIONAL HIGH SCHOOL —_NAGCARLAN, LAGUNA BLADDITIONAL INFORMATION, ‘Course Already Enrolled BS MECHANICAL ENGINEERING No.of Units __6 __Year Level a {AGUNA STATE POLYTECHNIC UNIVERSITY STACRUZGrsguating? YES ‘BRGY. BUBUKAL STA, CRUZ Expected Year of fe Address of Schoo! URAL Expected Ye 2022 ‘RELERENCES (Persons not related by consanguinity or affinity to applicant) ‘Name Address 1 MRS. ELEANOR S, MONTEFALCON E-URRA ST. NAGCARLAN LAGUNA 2 MR. ELYMAR A. PASCUAL, BRGY. OOGONG STA. CRUZ LAGUNA cy MR. FERIC ROBIS "ARELA SUBD. NAGCARLAN LAGUNA | hereby certify that I have read the terms and conditions governing, grant as provided for by the Scholarship Program of the Provincial Government of Laguna anc its implementing rules and regulations and hereby pledge strict observance and complianee therewith. Further, by affiing my signature, { am hereby giving my consent to process my personal dgta based on the Data Protection Policy Gaguna.govphiopa). With My Consent: Urinal KeA@ocoan ‘Signature over printed name of ParenGuardian Signafire over printed name of Student