Affiliations Type of ID ID Number GWA

APPLICANT’S PERSONAL INFORMATION

Last Name Gender Place of Birth Religion

First Name Date of Birth Age Civil Status Landline Number

Middle Name Mobile Number Email Address

HOME ADDRESS

Unit Number House Number Street Name/ Subdivision Barangay

CURRENT SCHOOL INFORMATION

Complete Name of School School Location School Type

Academic Grade / Level Course (for Senior High School and College only) If Graduating, (Expected Date of
Graduation)

FAMILY
INFORMATION
RELATIO NAM OCCUPATI MONTHLY
N E ON INCOME
Father ₱

Mother ₱

Guardian, ₱
as
applicable

If Self-Supporting Student: ₱ COMBINED MONTHLY ₱

INCOME

EDUCATIONAL
BACKGROUND

LEVEL COMPLETE NAME OF SCHOOL INCLUSIVE YEARS HONORS &

AWARDS
Elementar
y

Junior
High

Senior
High

Tertiary

MODE OF RECEIPT OF LATEST SCHOLAR ALLOWANCE

CASH CARD ACCOUNT NUMBER:

CONSENT AGREEMENT
I, (PCS applicant or legal guardian), a PCS applicant / acting as legal
guardian of
(name of the PCS applicant) who is currently applying for admission to the Pasig City
Scholarship Program, am giving my consent for the PCS Office to collect and process our personal data in relation to the purpose of
admission as PCS Scholar.

ACCEPTANCE OF TERMS
We affirm that the facts herein provided are true and correct as of the date hereof. We hereby authorize the Pasig City Scholars
Office and its authorized representatives to verify the information submitted. We understand that if awarded the benefits under the
PCS, any false statement, omissions, or misrepresentation made in this application form may result in the immediate withdrawal of the
scholarship grant.

PCS FORM V2
NOT FOR SALE
Signature of Applicant over Printed Name Signature of Parent/ Guardian over Printed Name
Date Signed: Date Signed:

PCS FORM V2
NOT FOR SALE
 THIS PAGE IS A SAMPLE ONLY.

Affiliations Type of ID ID GWA

RENEW - REGULAR SCHOOL ID Number 92%
11234566-
23
APPLICANT’S PERSONAL INFORMATION

Last Name Gender Place of Birth Religion

QUEZON CITY CATHOLIC
DELA CRUZ MALE

First Name Date of Birth Age Civil Landline Number

JUAN JUNE 01, 2010 14 Status N/A
SINGLE
Middle Mobile Number Email Address
Name 0968 999 9999 sampleonly@gmail.com
SANTOS

HOME ADDRESS

Unit Number House Street Name/ Subdivision Barangay

N/A Number 67 SAGAD
SAMPLE STREET

CURRENT SCHOOL INFORMATION

Complete Name of School Location School Type

School RIZAL HIGH PASIG CITY PUBLIC
SCHOOL
Academic Grade / Level Course (for Senior High School and If Graduating, (Expected Date of
GRADE 9 College only) N/A Graduation)
N/A

FAMILY
INFORMATION
RELATIO NAM OCCUPATI MONTHLY
N E ON INCOME
Father JOHN SY DELA CRUZ CARPENTER ₱ 5,000.00

Mother LYDIA SANTOS DELA CRUZ HOUSEWIFE ₱ 0.00

Guardian, JAMES SANTOS DELA CRUZ (BROTHER) WAITER ₱ 12,000.00

as
applicable

If Self-Supporting Student: ₱0.00 COMBINED MONTHLY ₱ 17,000.00

INCOME

EDUCATIONAL
BACKGROUND

LEVEL COMPLETE NAME OF SCHOOL INCLUSIVE HONORS &

YEARS AWARDS
Elementar CANIOGAN ELEMENTARY SCHOOL 2015-2021 WITH HONORS
y

Junior RIZAL HIGH SCHOOL 2021-PRESENT N/A

High

Senior N/A N/A N/A

High

Tertiary N/A N/A N/A

MODE OF RECEIPT OF LATEST SCHOLAR ALLOWANCE

OPTIONS ARE: LANDBANK (ATM) OR PAYROLL (NON-

ATM)

CASH CARD ACCOUNT NUMBER (If Landbank, input your Cash Card Number
here): 02114151255 For new applicants, write “PAYROLL” on the box. Write
N/A beside the Cash Card Account Number

CONSENT AGREEMENT
I, JOHN SY DELA CRUZ, (PCS applicant or legal guardian), a PCS applicant / acting as legal guardian of JUAN SANTOS DELA CRUZ
(name of the PCS applicant) who is currently applying for admission to the Pasig City Scholarship Program, am giving my consent for
the PCS Office to collect and process our personal data in relation to the purpose of admission as PCS Scholar.

ACCEPTANCE OF TERMS
We affirm that the facts herein provided are true and correct as of the date hereof. We hereby authorize the Pasig City Scholars
Office and its authorized representatives to verify the information submitted. We understand that if awarded the benefits under the
PCS, any false statement, omissions, or misrepresentation made in this application form may result in the immediate withdrawal of the
scholarship grant.

PCS FORM V2
NOT FOR SALE
JUAN SANTOS DELA JOHN SY DELA CRUZ
CRUZ
Signature of Applicant over Printed Name Signature of Parent/ Guardian over Printed Name
Date Signed: 05 SEPTEMBER 2024 Date Signed: 05 SEPTEMBER 2024

PCS FORM V2
NOT FOR SALE