Date Accomplished (Signature Over Printed Name) : Evaluated/Processed by

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Form 1 App.

No: 2022-09-27 820877O


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

CHED SCHOLARSHIP PROGRAMS (CSPs)


APPLICATION FORM
PERSONAL INFORMATION
Name BELLO Eday Even Salunoy
(Last Name) (First Name) (Middle Name)
Date of Birth March 02, 1997 Street/Barangay Barangay San Jose lope De Vega
Northern Samar
Place of Birth Barangay San Jose lope De Vega Town Catarman
Northern Samar
Sex Male Province Northern Samar
Civil Status Single District 1st
Contact No. 09813457382 Zip Code 6400
Email [email protected]
FAMILY BACKGROUND
FATHER ( ✔ ) Living ( ) Deceased MOTHER ( ✔ ) Living ( ) Deceased
Name BELLO Ernio Alimbuyong Niyok Name BELLO Aurora Salunoy
Address Barangay San Jose lope De Vega Address Barangay San Jose lope De Vega
Northern Samar Northern Samar
Educational Attainment Elementary level Educational Attainment Elementary level
Occupation Farmer Occupation House wife
LEGAL GUARDIAN
Name BELLO Aurora Salunoy Auring No. of Siblings 8
Address Parent(s)/Guardian Annual Gross Income P 1,500.00
Occupation DSWD's 4ps Beneficiary ( ) YES ( ✔ ) NO
ACADEMIC INFORMATION
Applicant Type A-HS Graduate Year Level in 2022-2023 1
High School Graduated LOPE De Vega senior high school Learner Reference Number 3035633130060
College NORTHERN SAMAR COLLEGES General Weighted Average 91
Degree Program/Course Bachelor of Science in Information Technology
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.

September 27, 2022 EVEN S. BELLO EDAY


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


BELLO EDAY EVEN SALUNOY

ADDRESS
BARANGAY SAN JOSE LOPE DE VEGA NORTHERN SAMAR, CATARMAN, NORTHERN SAMAR, 6400

OPY
DATE OF BIRTH PLACE OF BIRTH SEX CIVIL STATUS
MARCH 02, 1997 BARANGAY SAN JOSE LOPE MALE
DE VEGA NORTHERN SAMAR
' S C SINGLE

COLLEGE
NORTHERN SAMAR COLLEGES
U D ENT DEGREE PROGRAM/COURSE
BACHELOR OF SCIENCE IN INFORMATION TECHNOLOGY

APPLICATION ENTRY DATE


SEPTEMBER 27, 2022
ST
APPLICATION NUMBER
2022-09-27 820877O
GWA
91
FAMILY GROSS ANNUAL INCOME
P 1,500.00

_________________________ ____________________
Received By Date Received

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