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Document No.

WVSU-OSA-SOI-01-F02
FORM
Revision No. 0
Date of Effectivity: July 10, 2015
WEST VISAYAS STATE
Issued by: OSA
UNIVERSITY
Page No. Page 1 of 2

GOVERNMENT SCHOLARSHIP FORM


_____ Semester, SY _____________

Date: _____________

THE PRESIDENT
This University

Sir/Madam:

May I apply for the start/continuance of my _________________________


Scholarship for the SY, ___________, ________ Semester, I have complied with all
the requirements for the said scholarship. Thank you.

Very truly yours,

_________________________
Signature over Printed Name of Scholar
_________________________
Course/Year & Section
Recommending Approval:

______________________________
College Dean

Action Taken: ( ) Approved ( ) Disapproved

NANCY S. SURMIEDA, Ph. D.


Dean, OSA

A. PERSONAL DATA

Name of Student: ________________________________________ Course/Year &


Section: ______ STFAP Bracket: ____Name of Parents: ______________________
Age: _____ Birth Date: __________________ Gender: _________Complete Home
Address: _____________________________________________________ Contact
Number: _____________________________Scholarship enjoyed the previous term:
________________________________ Adviser: ___________________________
Document No. WVSU-OSA-SOI-01-F02
FORM
Revision No. 0
Date of Effectivity: July 10, 2015
WEST VISAYAS STATE
Issued by: OSA
UNIVERSITY
Page No. Page 2 of 2

B. ACADEMIC DATA
Subject Taken (Previous Grade No. of Instructor
Semester) Units

GPA: ___________Total:______ Checked by :___________


Section Adviser

Certified Correct:

____________________________
Director, Admissions and Records

ATTACH THE FOLLOWING DOCUMENTS

TES/UPSTEP/DOST/ISKOLAR SANG ILOILO/CHED/ILOILO CITY


SCHOLARSHIP/ MUNICIPAL SCHOLARSHIP -Contract/Notice of
Scholarship/Certification