UniFAST TDP Form Annex 1

2022 version
(NOT FOR SALE)

2x2
CHED Regional Office XII ID PICTURE
UniFAST TULONG DUNONG PROGRAM (UniFAST-TDP)
APPLICATION FORM
Instructions. Read General and Documentary Requirements. Fill in all the required information. Do not leave an item blank Item is not applicable, indicate "NA".

PERSONAL INFORMATION

Name (Last Name) (First Name) (Middle Name) Maiden Name

(for Married Women)
Date of Birth Permanent Address Zip Code
(mm/dd/yyyy)

Street & Town/City/ Province

Place of Birth
Barangay Municipality
Name of School Attended

___ Male School ID Number

Sex
___ Female School Address
Citizenship School Sector ( ) Public ( ) Private

Mobile Number Year Level Course Tribal Membership

(if applicable)
E-mail Address Type of Disability
(if applicable)
FAMILY BACKGROUND
Father: () Living () Deceased Mother: ( ) Living ( ) Deceased
Name
Address
Occupation
Are you enjoying other educational financial assistance? __Yes or ___No
If yes, please specify 1. _____________________________
2. _____________________________
QUALIFICATION REQUIREMENTS PRIVACY NOTICE
per Section 1 of the Memorandum Circular No. __ s. 2022. • In connection with my application for the Tertiary Education Subsidy (TES) Program/ Tulong-Dunong Program
(TDP), I authorize partner Higher Education Institutions (HEIs), the Commission on Higher Education (CHED),
An applicant for this grant must be a Filipino citizen with a combined household
and the Unified Student Financial Assistance System for Tertiary Education (UniFAST) Secretariat, its
(parents/guardian) gross income which shall not exceed Four Hundred Thousand
Pesos (PhP400,000.00) and maybe classified as one of the following: representatives, and outsourced service providers, if any, to collect, process update or disclose personal
information about me/us in accordance with the Data Privacy Act of 2012, its Implementing Rules and
5.1 New TDP-TES Grantee must be enrolled in any first undergraduate degree in Regulations (IRR), and to verify, my personal information from any person or entity that may deem necessary
SUCs, CHED-Recognized LUCs and Private HEIs that are in the CHED Registry under applicable laws, rules, and regulations.
of Programs and Institutions.
CONSENT
DOCUMENTARY REQUIREMENTS per Section 3 of the Memorandum
Circular No. __ s. 2022. • I agree to hold partner HEIs, CHED, and UniFAST and the persons or entities from whom it may obtain, or
6.2.1 a. For new applicants: with whom it may disclose or verify my personal information free and harmless from any liability arising from
Participating higher education institutions (HEIs) must submit, to the respective the use of any information.
CHED Regional Offices, a certified true copy or electronically-generated copy of the • I confirm that I am aware that under the Data Privacy Act, I have (a) the right to withdraw the consent hereby
list of enrolled student- applicants with total number of units enrolled (Annex 5), with given or to object to the processing of my personal information provided there is no other legal ground or
the attached certified electronically generated Certificate of Registration/Enrolment
overriding legitimate interest to the processing thereof; (b) right to reasonable fees, (c) right to rectification,
(CORs/COEs) as proof of enrollment.
and (d) right to erasure or blocking of my personal information subject, however, to the conditions for the
6.2.2 (Income Requirement) New applicants and continuing grantees shall submit legitimate exercise of the said rights under the Data Privacy Act and its IRR, and subject further to the right of
a Certificate of Indigency as proof of income, duly issued by the Punong Barangay partner HEIs, CHED, and UniFAST to terminate the program availed by me should I withdraw my consent or
where the applicant resides. request the removal of my personal information.

I hereby certify that foregoing statements are true and correct.

___________________________________ ______________________________
Signature over Printed Name of Applicant Date Accomplished
Note: Fully accomplished form to be submitted to the CHEDRO
DO NOT FILL-OUT THIS PORTION FOR CHEDRO USE ONLY)

Documents Attached
Certificate of Registration/Enrolment (CORs/COEs) _________
Certificate of Indigency _____
____ _________
Evaluated /Processed by:
______________________________
UniFAST Regional Coordinator