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Recent 2x2 Picture

Format (please follow this format)

CHED DISSERTATION GRANT 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Name nominee/applicant ______________________________________ (first) (Middle) (Last) Date and Place of birth Mailing/Office address and telephone/fax number Residence and telephone number E-mail address Civil status (If married, pleases indicate spouse and children) Educational background (Indicate school/university address, degree and year obtained, inclusive dates of attendance, honors/awards received) Present position Subjects currently taught Previous positions in chronological order Title of dissertation proposal Discipline of study Degree program Name and address of University/College where the candidate grantee is enrolled Name of Dissertation Adviser Work Plan/Time Table Expected Date of Completion

Activities Approval of Dissertation Proposal Data Collection and Encoding Data Analysis Dissertation Writing Expected Date of Defense Expected Completion Date of Doctoral Program

17. Total Amount and Detailed Budget of Financial Assistance sougth from CHED Dissertation Grant Item Amount

* Please indicate other source (s) of financial support including the amount

18. 19. 20. 21. 22.

Dissertation Panel/Committee Members Awards received (indicate year received and name of awarding institution/organization) GPA in the Course leading to the program applied for Research Publications (Give complete citation and include manuscript in press) Research papers and studies completed or in progress (indicate where or when conducted, date completed or expected date of completion, and include only those not listed in item 20) 23. Membership in professional organizations (indicate position/nature of involvement) 24. Conferences/seminars and extent of participation, i.e. whether as chairperson, resource person, convenor, participants, etc.

This is to certify the correctness of the information presented above.

______________________________________________ Name & Signature of the Faculty Applicant Date: ________________

_______________________________ Name & Signature of the School Head Date: _____________

Note: Please submit two (2) copies of the accomplished application form including copies of (a) approved dissertation proposal including a one page abstract (b) two 2x2 photographs, (c) letter of recommendation from the dissertation adviser (d) endorsement letter from the applicants mother institution (e) photocopy of the latest enrollment/registration form.