Form 1 App.

No: 2021-07-20 502128O

Office of the President of the Philippines
COMMISSION ON HIGHER EDUCATION
REGIONAL OFFICE VIII

CHED SCHOLARSHIP PROGRAMS (CSPs)

APPLICATION FORM
PERSONAL INFORMATION
Name LAGERA Shella Mae Merencillo
(Last Name) (First Name) (Middle Name)
Date of Birth March 06, 2002 Street/Barangay BARANGAY TIGBAO
Place of Birth CARIGARA Town Carigara
Sex Female Province Leyte
Civil Status Single District 2nd 2
Contact No. 09991718062 Zip Code 6529
Email Raellelagera@gmail.com
FAMILY BACKGROUND
FATHER ( ✔ ) Living ( ) Deceased MOTHER ( ✔ ) Living ( ) Deceased
Name LAGERA Armando Agunos Name LAGERA Nelia Merencillo
Address BARANGAY TIGBAO CARIGARA Address BARANGAY TIGBAO CARIGARA
LEYTE LEYTE
Educational Attainment GRADE 3 LEVEL ELEMENTARY Educational Attainment THIRD YEAR HIGHSCHOOL LEVEL
Occupation FARMER Occupation HOUSEWIFE
LEGAL GUARDIAN
Name LAGERA CHRISTENE MAE No. of Siblings 6
Merencillo
Address Parent(s)/Guardian Annual Gross Income P 4,700.00
Occupation DSWD's 4ps Beneficiary ( ✔ ) YES ( ) NO
ACADEMIC INFORMATION
Applicant Type A-HS Graduate Year Level in 2021-2022 1
High School Graduated CARIGARA NATIONAL Learner Reference Number 121281070013
VOCATIONAL SCHOOL
College WESTERN LEYTE COLLEGE OF ORMOC General Weighted Average 90
Degree Program/Course Bachelor of Science in Nursing
Are you enjoying other source of educational/financial assistance? ( ) YES ( ✔ ) NO
If YES, please specify Type Agency
OTHERS
YES NO
✔ Indigenous and Ethnic People (IP), please specify membership
✔ Dependent of Solo Parent
✔ Persons with Disabilities (PWDs), please specify type of disability

I hereby certify that foregoing statements are true and correct. Any misinformation or witholding of information will automatically disqualify me from the CHED
Scholarship Program. I am willing to refund the financial benefits received if such information is discovered after acceptance of the award.

I hereby express my consent for the Commission on Higher Education to collect, record, organize, update or modify, retrieve, consult, use, consolidate, block, erase
or destruct my personal data as part of my information. I hereby affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my
personal data and be indemnified in case of damages pursuant to the provisions of the Republic Act No. 10173 of the Philippines, Data Privacy Act of 2012 and its
corresponding Implementing Rules and Regulations.

July 20, 2021 SHELLA MAE M. LAGERA

Date Accomplished (Signature over Printed Name)

DOCUMENTS ATTACHED REMARKS

1. Citizenship
( ) Duly certified true copy of Birth Certificate

2. Academic
( ) Duly certified true copy of Report Card - For SH/HS
Graduate
( ) Duly certified true copy of Grades: Grade 11 and 1st
semester of Grade 12 - For Graduating Senior HS

3. Financial
( ) Income Tax Return ( ) Tax Exemption
( )Certificate of Indigency ( ) Case Study
( )OFW Contract

4. Others
( ) Solo Parent ( ) Senior Citizen
( ) IPs ( ) PWD

Evaluated/Processed by

__________________________________ ________________________________
CHED StuFAPs Coordinator Date
 Office of the President of the Philippines
COMMISSION ON HIGHER EDUCATION
REGIONAL OFFICE VIII

CHED SCHOLARSHIP PROGRAMS (CSPs)

ACKNOWLEDGEMENT RECEIPT

LAST NAME FIRST NAME MIDDLE NAME

LAGERA SHELLA MAE MERENCILLO

ADDRESS
BARANGAY TIGBAO, CARIGARA, LEYTE, 6529

OPY
DATE OF BIRTH PLACE OF BIRTH SEX CIVIL STATUS
MARCH 06, 2002 CARIGARA

' S C FEMALE SINGLE

ENT
COLLEGE DEGREE PROGRAM/COURSE
WESTERN LEYTE COLLEGE OF ORMOC BACHELOR OF SCIENCE IN NURSING

T U D
APPLICATION ENTRY DATE
JULY 20, 2021 S
APPLICATION NUMBER
2021-07-20 502128O
GWA
90
FAMILY GROSS ANNUAL INCOME
P 4,700.00

_________________________ ____________________
Received By Date Received

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