PHILIPPINE-CALIFORNIA ADVANCED RESEARCH INST ITUTES • At tach here passport size p ic ture

taken w i t h i n the last 3 m o n t h s

SCHOLARSHIP APPLICATION FORM A.Y, 2015-2016

TYPE OF SCHOLARSHIP APPLIED FOR

I 1 M.S. Local

• M.S. Overseas

I. PERSONAL INFORMATION

[ I Ph.D. Local

• p h .D. Overseas

• Postdoctora l Study Award

• Master 's Sandwich Program | | Doctora l Sandwich Program

a.

Last Name First Name Middle Name

b.

Permanent address No. Street City/Municipality Province

c.

Zip Code Region District Passport No. E-mail Address

d.

Current Mailing Address

Telephone Nos. (Landllne/Moblle) Fax. No.

Civil Status Date of Birth Age Sex

Name of Father

H. Name of Spouse

Address

Occupation

Office Address

Number of Dependents

(Use additional sheet if necessary)

Name of Mother

Name of Dependent Birthday Relation to Applicant

II. INFORMATION ON CHED & DOST SCHOLARSHIP AND OTHER PREVIOUSLY/CURRENTLY AVAILED OF

SCHOLARSHIP/GRANT YEAR OF AWARD FIELD UNIVERSITY/ SCHOOL REMARKS

MS

DOST-PSHS

MS OTHERS

CHED-TD

CHED-SNPLP

CHED-DCP

OPAPP-CHED STUDY GRANT

PROGRAM

B.S. CHED-SGP-PA

CHED-PAMANA

CHED-SBGP

DOST-RA 7687

DOST-MERIT

DOST-JLAP

OTHERS

PCARl Scho la rsh ips Pro jec t I version 07.2015 IL

M.S.

CHED-FDP

M.S.

CHED-SE6S

M.S.

DOST-NSDB/NSTA

M.S.

DOST-ASTHRD

M.S. DOST-ERDT

M.S.

DOST-COUNCIL/SEI

M.S.

PCARl

M.S.

OTHERS

Ph.D.

CHED-FDP

Ph.D.

CHED-SEGS

Ph.D.

DOST-NSDB/NSTA

Ph.D.

DOST-ASTHRD

Ph.D. DOST-ERDT

Ph.D. DOST-

COUNCIL/SEI

Ph.D.

PCARl

Ph.D.

OTHERS

III. DEGREE PROGRAMS (For M.S./Ph.D. Applicants Only) New Applicant

a. University where you applied/

Intend to enroll

b. Course/Degree

Lateral Applicant

a. University enrolled in

b. Course/Degree

c. No, Of units earned d. No. Of remaining units/sems

IV. NOIM-DEGREE PROGRAMS (For Postdoctoral/Stand-alone Sandwich Programs Applicants Only)

POSTDOCTORAL STUDY AWARD New Applicant

a. University where you applied/

Intend to enroll

b. Degree Earned/University where you earned your degree

Lateral Applicant

a. University enrolled in

b. Degree Earned/University where you earned your degree

c. Research/Project Area

STAND-ALONE SANDWICH PROGRAMS a. University enrolled in

b. Degree Earned/University where you earned your degree

c. Research/Project Area

d. Overseas University where he/she will conduct the dissertation

PCARl Scho la rsh ips Pro jec t | Version 0 7 . 2 0 1 5

CAREER/EMPLOYMENT INFORMATION Present Employment Status; B Permanent

Self-employed s Contractual

Unemployed • Probationary

a . l For those who are presently employed

Position

Company

Address

E-mail

Telephone No,

a.2 For those who are self-employed

Business Name

Address

Email/Website

Type of Business

Website

Fax No,

Telephone No.

Years of Operation

Fax No. Telephone No.

Years of Operation

*Once accepted into the scholarship program, the scholar must obtain permission to take a Leave of Absence (LOA) from his/her employer and become a ful l-t ime student. The scholar must submit a letter f rom his/her employer approving the LOA.

b. Narrative on Applicant's Current Work, Outstanding Qualities, Career and Research Plans (Write in separate sheet attached to this form)

b . l Provide a narrative of not more than one thousand (1000) words, describing the applicant's current work or project (or research) that s/he worked on and his/her contribution towards the completion of the project.

b.2 Provide a narrative of not more than five hundred (500) words, describing the qualities that make (you) the applicant outstanding in a highly competitive process (e.g., academic excellence, development potential, financial need, etc.)

For Master's Scholarship applicant, a narrative, not more than five hundred (500) words, describing his/her intended research area and what the applicant intends to do (e.g., work, business, etc.) after earning his/her graduate degree. For Doctoral Scholarship and Postdoctoral Fellowship applicants, a narrative, not more than 500 words, describing his/her intended research area, e.g., a "Statement of Purpose".

VI. RESEARCH AND DEVELOPMENT INVOLVEMENT (last five years)

Use additional sheet i f necessary.

FIELD AND TITLE OF RESEARCH LOCATION/DURATION FUND SOURCE NATURE OF INVOLVEMENT

VII. PUBLICATIONS (last five years)

Use additional sheet i f necessary.

TITLE OF ARTICLE/PUBLICATION PLACE/YEAR OF PUBLICATION NATURE OF INVOLVEMENT

VIM. AWARDS RECEIVED Use additional sheet i f necessary.

TITLE OF AWARD AWARD GIVING BODY YEAR OF AWARD

I hereby certify that all information given above are true and correct to the best of my knowledge.

Signature of Applicant

Date

I . PCARI Scholarships Project | Version 07.2015

CHECKUST OF REQUIRED DOCUMENTS SUBMITTED (for staff use only)

D Curriculum vitae covering personal, educational (including research projects if applicable),and professional {type of work and position occupied) background.

• Recommendation tetter from three (3) past professors or supervisors 0 Birth certificate (original N50 copy and photocopy)

• Admission letter (Note: For overseas scholarship, admission fetter will only be required from pre-qualified applicants.)

• Medical Cerificate from a licensed physician indicating PRC License No. 0 Grades or official transcript of records • Diploma or certificate of graduation Certification of no pending cases from • N8i

Employer (University for new graduates) •

Staffs Signature

Date: