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Don Mariano Marcos Memorial State University

La Union, Philippines

FREE HIGHER EDUCATION APPLICATION FORM

Directions: Fill-up by putting a check mark (/) on the appropriate box or by writing the needed information. Please write legibly.

I. PERSONAL INFORMATION ID No. _____________


Name Sex: Male Female
Contact Number Civil Status: Single Married
E-mail address Home Address:

II. FAMILY INFORMATION


Name of Father:_______________________________
Name of Mother:
Who is supporting your studies?
Parents
Does your family belong to any of the following? Self-supporting
4Ps Beneficiaries Spouse (if married)
Listahan 2.0 Others, please specify,
Not Applicable
If supported by the parents, Number of Siblings below 18 years old:
If married and supported by the spouse, number of children below 18 years old:
Monthly Family Income
Occupation Estimated Monthly
Income
If supported by parents Father
Mother
Total Monthly Income
If supported by spouse
If self -supporting

III. STUDENT INFORMATION


Course:

Type of Student: New If New, when was the last school year attended:
Continuing and in which institution (name of school):
Old Student Returning

Year Level:
Graduating Non Graduating
th th nd
6 Year Graduating 4 Year 2 Year
th rd st
5 Year Graduating 3 Year 1 Year
th
4 Year Graduating

Are you a recipient of any scholarship? Yes No


If yes, write the name of the scholarship program and total amount of stipend per semester

I hereby certify as to the correctness of the information provided and I am willing to undergo the Return
Service System as stated on Rule II Section 4 of the Implementing Rules and Regulations of Republic Act
No. 10931.

Signature of Applicant
Signature of Parent/Guardian
========================================================================================================
(Do not write on this part, for SAS Personnel)
CONFIRMATION SLIP
Date: _________________

This confirms that _______________________________________is granted FREE Higher Education for the 1st Semester SY: 2019-2020.
(Name of Student)

Endorsed by: Assessed by: Approved by:

______________________ MRS. ANGELITA S. DOMONDON DR. BERNARDO D. LAMADRID


Guidance Counselor Campus In-charge, Scholarship and Financial Assistance Head, Student Affairs and Services
PROCESS FLOW CHART FOR THE APPLICATION FOR FREE HIGHER EDUCATION

Get Free Higher Education Application Form from the


Office of the Guidance Counselor

Submit Application form at the

Office of the Guidance Counselor

Assessment by the Scholarship Coordinator


and Approved by the SAS Head

Confirmation of Grant

ENROLLMENT

Requirement:

For New Student:

 Photocopy of senior High school report card.

For old student:

 Printed grades from the Student Portal certified by Department Chairperson and
endorsed by College dean.

Fn:universityregistrar/FEapplicationform/D