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Application Form

GSIS application form for scholarship program 2018

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN
(GOVERNMENT SERVICE INSURANCE SYSTEM)
Financial Center, Roxas Boulevard, Pasay City 1308

APPLICANT’S COPY

GSIS SCHOLARSHIP PROGRAM (GSP) FOR AY 2017-2018
Application Period: 10 April to 9 June 2017

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All active and regular GSIS members at the time of application with premium payments for the last six (6) months and are
permanent employees in the government with at least three (3) years of service and with salary grade of 24 or below or its
equivalent job level are eligible to apply.
Likewise, all Permanent Total Disability (PTD) pensioners who are below sixty (60) years of age may nominate their children for
scholarship, with their last compensation to be used as basis for the selection process. From hereon, PTD pensioners shall also
be referred to as “members”.
The member is allowed to nominate one (1) scholar who meets the following qualifications:
a. Must be a child of a member, including the child/dependent of solo parent-member as defined under The Solo Parents’
Welfare Act or the dependent of a childless married or single member; and
b. An incoming college freshman-dependent or a college student-dependent in any year level who is accepted in or taking up
any 4- or 5-year course (Annex A) at schools identified by the Commission on Higher Education (CHED) in a Higher
Education Institution (HEI) with its own charter or a school qualified by the CHED as Levels IV and III, Autonomous or
Deregulated (Annex B).
Eligible members may secure an application and certification forms (see reverse portion) from any GSIS office or may download
the same from the GSIS website (www.gsis.gov.ph).
For all applicants, please submit the following requirements to the nearest GSIS office for processing:
a. Duly accomplished forms
b. Dependent’s Birth Certificate
For applicants with sectoral group affiliation, please submit the following additional requirements:
a. Endorsement from the head of agency/office attesting to the veracity of claim that you belong to the sector you have checked
b. Original/certified true copy of government-issued authentication, i.e. PWD ID from the local social welfare development office
(LSWDO) or National Council on Disability Affairs; Certificate of Confirmation of Tribal Membership from National
Commission on Indigenous Peoples; and SP ID from LSWDO.
Eligible GSIS members will be selected based on their annual basic salary and length of service.
The scholar shall be entitled to the following benefits during the 4- or 5-year course duration:
a. Actual cost of tuition and miscellaneous fees not to exceed P40,000.00 per academic year, regardless of the number of
terms (not to include summer classes and provided that the course is finished within the regular duration prescribed by the
school for that 4- or 5-year course); and
b. Monthly stipend of P3,000.00.
The scholarship grant is non-transferable.
Only those who complied with abovementioned requirements are qualified to apply.

GSIS COPY

GSIS SCHOLARSHIP PROGRAM AY 2017-2018 APPLICATION FORM

INSTRUCTIONS: Please print and complete all entries in capital letters and check the appropriate box. Attach birth certificate and other
required documents.

Name of Member-Applicant ___________________________________________________________________________________
(LAST)

(FIRST)

(MIDDLE)

Complete Home Address _____________________________________________________________________________________
GSIS BP No. _____________________ Date of Birth (mm/dd/yyyy) __________________ Home Phone ____________________
Mobile No _______________________________________ Email Address ____________________________________________
Civil Status
Single
Married
Separated
GSIS Status
Active member
PTD pensioner
Sectoral Group Affiliation (if applicable):

Solo/Single parent(SP)

Person with disability(PWD)

Indigenous people (IP)

Agency Name _________________ Agency Address ______________________________________________________________
Type of Agency

Nat’l Gov’t

LGU

GFI

GOCC Others, pls. specify ______________________________

Office Phone No. ________________ Position ________________________________ Years in Gov’t Service _______________
Salary Grade (If based on job level, indicate equivalent salary grade) ______________________ Annual Basic Salary ______________________
Name of Spouse (if applicable)___________________________________________________________________________________
(LAST)

(FIRST)

(MIDDLE)

Occupation _________________________________Agency/Address ________________________Mobile No. _______________
Name of Dependent __________________________________________________________________________________________
(LAST)

(FIRST)

(MIDDLE)

Relationship to the Member-Applicant _______________Gender _______Course Title __________________________________
Year Level this 1SemAY2017-2018 ________ Course Duration
4 yrs
5 yrs
Others (indicate no. of years/months) __________
Month when semester would start: 1sem ________2sem __________
School Name ___________________Complete School Address Accepted/Enrolled_____________________________________
______________________________________________________

Applicant’s Signature over Printed Name

_______________________________________

Date Accomplished
 
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