PHI KAPPA MU FRATERNITY

SCHOLARSHIP AND FINANCIAL ASSISTANCE PROGRAM

University of the Philippines-Manila, College of Medicine

APPLICATION FOR SCHOLARSHIP For School Year _____to_____

Name of Applicant_Kenneth Roy Perez Mendoza Year Level 3 Phi Batch 2010

Place of Birth Dasmarinas Cavite__________________ Citizenship Filipino

Date of Birth July 28, 1989________________________ Civil Status Single ____

Permanent Address 59 Aguinaldo St. Brgy. Kalayaan Angono, Rizal Tel #_N/A_ _

City Address________________________________________ Tel #_ N/A_ _

Mobile #_09065476021 / 09227899389__________

Name of Wife (if applicant is married)_____N/A_____________ Occupation___N/A_________

Name of Children/ Age _______N/A___________________________

__________________________________

__________________________________

Father_Bienvenido M. Mendoza_____________________________Age__52________

Occupation(indicate if retired, unemployed or deceased)__unemployed_______________

Salary (Annual)___________________________N/A___________________

Mother_Carmelita P. Mendoza____________________________Age___43_________

Occupation(indicate if retired, unemployed or deceased)__Regional Trial Court Stenographer_____

Salary (Annual)____160,000 Pesos___________________________________

if both parents are unemployed or deceased, state source of livelihood:

_vehicle for hire_ Amount (Annual)__120,000 Pesos______________

Guardian______________________Occupation_____________Salary_____

Relation_______________________

TOTAL ANNUAL FAMILY INCOME:___280,000 Pesos____________________

Siblings (for unmarried applicants only) use additional sheets if necessary

Name Age Civil Status Income (if working)

_Kevin Carl P. Mendoza__ _18__ Single _____________________

_Kolette Vivien P. Mendoza _7____ Single _____________________

______________________ _____ _______ _____________________

Please answer the following:

1. Are you enjoying any scholarship, financial assistance, employment or
other privileges in the University?____No_____ Outside the University?
___No_____

2. If you answered “yes” to both or either of the questions in number 1,

specify nature and amount of grant or salary?____________________
________________________________________________________

3. Do you or your parents own real properties?__Yes___

If yes, specify: use additional sheets if necessary
Property Market Value
_House and lot ___________ ______150,000 Pesos_______

__________________________ __________________________

4. Do you or your parents own other properties ( specify, ex. Cars, stocks,
etc.) use additional sheets if necessary

Property Market Value

__Isuzu Hilander __________ ________500,000 Pesos_______

_________________________ ___________________________

5. If applicant’s parents are separated, state support being given by father

and/ or mother._______________________________________________

I hereby certify that all the statements above are true and correct.

_Kenneth Roy Perez Mendoza__ _November 1, 2010________

Signature of Applicant Date signed