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    Tibiao Application Form-2

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    netobernesto

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    © All Rights Reserved
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    Tibiao Application Form-2

    Uploaded by

    netobernesto
    5 views1 page

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    5 views1 page

    Tibiao Application Form-2

    Uploaded by

    netobernesto

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    © All Rights Reserved
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    REPUBLIC OF THE PHILIPPINES NOT FOR SALE

    PROVINCE OF ANTIQUE REVISED 2024


    OFFICE OF THE PROVINCIAL YOUTH DEVELOPMENT OFFICER

    PROVINCIAL EDUCATIONAL ASSISTANCE


    APPLICATION FORM
    FOR COLLEGE/UNDERGRADUATE STUDENT
    PWD Type of Disability: IP Name of Tribe: LGBTQ NONE
    I. PERSONAL & FAMILY INFORMATION

    NAME: DATE OF BIRTH:


    , ,
    Surname Given Name Middle Name MM/DD/YYYY

    PERMANENT ADDRESS: , TIBIAO , ANTIQUE


    Barangay Municipality PROVINCE

    PRESENT ADDRESS: , , CIVIL STATUS: AGE: SEX:


    Barangay Municipality/City Province

    FATHER’S NAME: , ,
    Given Name Middle Name Surname

    OCCUPATION: CONTACT NO:

    MOTHER’S MAIDEN NAME: , ,


    Given Name Middle Name Surname
    OCCUPATION: CONTACT NO:

    PARENT’S COMBINED ANNUAL INCOME: ITR/ESTIMATED INCOME PER YEAR


    If married, SPOUSE’S NAME: , ,
    Given Name Middle Name Surname

    II. EDUCATIONAL BACKGROUND

    SCHOOL: COURSE & YEAR:

    ACADEMIC YEAR: STUDENT ID NO: GOVERNMENT ID NO:

    III. CONTACT INFORMATION

    MOBILE NO: FACEBOOK ACCOUNT: GMAIL:


    By affixing my signature, I hereby give consent to OPYDO - Antique for the fair use of my information stated herein for lawful purposes, pursuant to
    R.A. 10173 (Data Privacy Act of 2012).

    Requirements Checklist: (To be check by the PYDO Staff/In-Charge)


    Educational Assistance Application Form (2 copies)
    Registration Form (Certified True Copy)
    Summary of Grades/Report of Ratings (Original Copy/Certified SIGNATURE OVER PRINTED NAME
    True Copy for 2nd - 5th Year only)
    (To be filled out by the PYDO Staff/In-Charge)
    Validated School Identification Card/any valid issued
    Government ID (Certified True Copy with 3 Specimen Signature) VERIFIED BY:
    PSA/NSO Marriage Certificate for married female (Photocopy)
    ENCODED BY:
    Remark/s: DATE OF CONTRACT SIGNING:
    1.)
    2.)

    DATE OF CONTRACT SIGNING:

    NOTES:
    1. Compile all the required documents along with the Application Form in a white long-sized folder.
    2. School requirements/documents must be certified true copy by the School Registrar.
    3. Grades must be complete. No INC and dropped subjects.

    This serves as proof that we have received your application for educational assistance for Academic Year 2024-2025 .
    If you have questions and concerns, you make contact OPYDO Tel No. 036 - 540 - 1542.
    NAME: SIGNATURE:
    PERMANENT ADDRESS:
    VERIFIED BY:
    OFFICE OF THE PROVINCIAL YOUTH DEVELOPMENT OFFICER
    Provincial Youth Development Office - Antique 2nd Floor, Media Center, Binirayan Sports Complex, pydevelopmentofficeantique@gmail.com
    San Jose de Buenavista, Antique 5700

    By affixing my signature, I hereby give consent to OPYDO - Antique for the fair use of my information stated herein for lawful purposes, pursuant to
    R.A. 10173 (Data Privacy Act of 2012).

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