Student Assistant Application Form

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CSFA- 001- 03

MAPUA INSTITUTE OF TECHNOLOGY Center for Scholarships and Financial Assistance

Application Form for Student Assistantship: (New Applicant)
Please print this on 8.5”x13” size bond paper

1 ½” x 1 ½”

PERSONAL DATA
Name
Surname First Name Middle Name

Student Number Remaining Units Including This Term Date of Birth Citizenship Address in Metro Manila: Residing at: [ ] Boarding House [ ] Parent’s House

Program of Study & Year Remaining Terms to Graduate Age Gender Place of Birth Civil Status

Existing Scholarship/s, if any

E-mail Address Religion Contact Number/s

[ ] With Guardian: _____________________

Permanent/ Provincial Address:

Contact Number/s

FAMILY BACKGROUND
Father’s Name Occupation Home Address Name of the Company or Business/ Address Mother’s Name Occupation Home Address Name of the Company or Business/ Address Brothers/ Sisters [use extra sheet of paper if necessary]

Age Net Annual Income Contact Number/s Contact Number/s Age Net Annual Income Contact Number/s Contact Number/s Program Presently Taking/ Finished

Age Name

School/ Location or Occupation/ Company

Total Number of Sibling/s: ______

Number of Working- Sibling/s: _______

Number of Studying- Sibling/s: ______

EDUCATION- Secondary Level
School/ Location Honors/ Awards Received Year Graduated General Average

Organizations

Rank among the Graduates:

Others: list other school you have attended and indicate the course/s you took from that school (i.e. computer courses, etc.)

MAPUA CORE VALUES:

Discipline Excellence Commitment Integrity Relevance

MATRIX OF GENERAL WEIGHTED AVERAGE

Year Level
1st year 2nd year 3rd year 4th year

General
1st Term

Weighted
2nd Term

Average
4th Term

SCHOLARSHIP/S RECEIVED

3rd Term

Reason/s for Availing Student Assistantship: _________________________________________________________

____________________________________________________________

______________________________ ____________________________________________________________

___________________
ATTITUDES/ CHARACTERISTICS:

Strength/s: ____________________________________________________________

______________ ____________________________________________________________

______________________________ ____________________________________________________________

____________________ Weakness/es: ____________________________________________________________

____________ ____________________________________________________________

______________________________ ____________________________________________________________

____________________
Current Membership in Organizations (in Mapua and off- campus)/ Extra- Curricular Activities: Name of Organization/s Position 1] ____________________________________________________________

________ _______________________________ 2] ____________________________________________________________

________ _______________________________ 3] ____________________________________________________________

________ _______________________________ TABULATED CLASS SCHEDULE (Please Write Room Assignment) Monday Tuesday Wednesday Thursday 7:30- 9:00 am 9:00- 10:30 am 10:30- 12:00 nn 12:00- 1:30 pm 1:30- 3:00 pm 3:00- 4:30 pm 4:30- 6:00 pm 6:00- 7:30 pm 7:30- 9:00 pm Friday Saturday Sunday

Total Duty Hours/ day Total Class Hours/ day Total DH + CH/ day

Total Duty Hours/ week: ____
I hereby certify that the above information is true and correct. Any misrepresentation of facts will render this form invalid and will immediately disqualify my application to this student assistantship.

_________________________________
Student’s Signature above Printed Name

______________________
Date Submitted

Recommended by:
Other Requirements:

__________________________________________ Immediate Head’s Signature above Printed Name ___________/_______________________________ Position---Department/ Unit/...
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