Document No.

WVSU-OSA-SOI-01-F02
GOVERNMENT Issue No. 1
SCHOLARSHIP FORM
Revision No. 1
Date of Effectivity June 30, 2023
WEST VISAYAS STATE
Issued by: OSA
UNIVERSITY
Page no. Page 1 of 1

______ Semester, AY _____________

Date: ________________

______________________________
Dean/Head, Office of Student Affairs
This University / Campus

Madam/Sir:

This is to inform your office that I am a recipient of ________________ Scholarship

for the Semester of Academic Year ______________. I have complied with all the
requirements of the said scholarship.

Thank you.

Respectfully yours,

Signature over Printed Name of Scholar

Noted:

_________________________
Dean/Head, Office of Student Affairs

A. PERSONAL DATA

Name of Student (All Caps): _________

Last Name Given Name Extension Name Middle Name
Course,Year & Section: Age: Birth Date: __
Sex: ________ Name of Parents/Guardian: ________
Contact Number: ____________ Email Address: _________________________
Complete Permanent Address: ____________________________________________
Scholarship enjoyed the previous semester: ______________________________________

B. ATTACH THE FOLLOWING DOCUMENTS:

Contract/Notice of Scholarship/Certification
Copy of Grades (IUIS/ Certification or other equivalent forms)