ere eee nd Republic of the Philippines cere 7G APP, NO. Department of Science and Technology eee I | J ETT since ‘SCIENCE EDUCATION INSTITUTE cane ERNE (Taxable & Nontaxable) Pe P.O. Box 18 Taguig Post Office A AAhENTRESSIGNATURE 1 ‘vq, Electity Consumption for months Anal HS Net Tuton & Otter Sol Fees. 2019 DOST-SEI Attach recent erect ssesamen SCIENCE AND TECHNOLOGY vx Scholarship Program Assessment F maser UNDERGRADUATE SCHOLARSHIPS photo here MERIT 200.000 No APPLICATION FORM Once official stamped DO NOT detach shat Printed Name/Signaiure | Deadline for Filing of Application: August 31, 2018 Attach another copy stl DST RO. No. ‘chedule of Examination \ctober of the same 1" x1" photo [J se: _| posto No. __ | Schedule of €: ti ‘October 21, 2018 Te the Tost Borat Ee rnrectod along I. PERSONAL DATA Asvessod by Name of Applicant ssf ans, Frs Nae Suh fone) Date of Birth iwwonwvy) | Place of Birth Number of Children in the | Birth Order of Applicant chs ets wie) / Family Sex Mobile Phone No. Email address: Citizenship Male OFemale Permanent Addross House Lot | Tyee ears | | Ne ‘Type of School ‘Senior High School Strand rogue Po Cseenca tis Cervatenis Cl unverstcaen UisTem —CINON-STEM Name of Schoo! Tuition and Other School Fees Paid in a Private High Schoo! ‘Address of Schoo}: 1, FAMILY DATA Father Mother Name Highest Educational Attainment Occupation ins secciy Name of Employer Employer Address 201 If seltemployed, declare 2017 Annual Gross Income Is your household included in the DSWD Listahanan 2.07 Yes ONo Is your family a beneficiary of the DSW wid Pamilyang Pilipino Program (4Ps)? Yes — ONo TIT. SCHOLARSHIP INTENTIONS DATA Check apprnpate bo RA 7687 SCIENCE AND TECHNOLOGY SCHOLARSHIP For applicant who belongs to a family whose socio-economic status does not exceed the set values of ALL the identifed indicators as approved by the Advisory Commitee on SAT Scholarships. otarship program apples far DOST-SEI MERIT SCHOLARSHIP For an applicant who belongs to a family whose socio-economic statu Applicant must pay a non-refundable test fee of P200,00. (ceeds the set values of any of the identified indicators,FORM B — HOUSEHOLD INFORMATION QUESTIONNAIRE (HIQ) I. HOUSEHOLD PROFILE Profle of housenold members (Please meluae ony the parents, applicant and applicant's Sbiags who are single. ago 27 and below, Wve undor tho same roo! and share in commen ooo} / lang ang mga magulang, apikante at mga kapaté ng aplkante na walang asa, may edad 21 pababs, Kasalukuyang nakatra sa bahay at kasama sa ininaany oagkai.) Name Relationship] Age| Civil | Highest | Grade or Year | Occupation of | Glass of | Gross Income iavosaraefretinihe tet ncuse | ta Applicant Status Educational | Attending i | Working | Worker | for the Year ome of aon Attainment | Currentlyin | Household | (See | 2047 in pesos) E285 | eety gree, |” Schoo! Member | se 1 2 4 6 Z a 6 “rae ic ta la of ere ome oar ore can oc a Raha] STShae for pate Housed ~ Employer n oun family pets tamitusress UsUnerown “sore onner aresamatory H-Unempioyed (eg houssufe) . FINANCIAL CONTRIBUTION IF Goth parents are unemployed, do you have any relates other than those inthe profile of household members (whether hare or abroad) who conf meeting your foray and seca! expenses? LI¥es LINO. Purpose of Financial Contribution Relationship of Gontributorto Applicant | Frequency of Contribution | Annual Contribution ie. edventona eestor) Ye bother whos sn OPM one ses blo nese Codes for Colum 3 (Funny of Canintans A= Worthy B-uately—C-Sem Annual Donal C= Inegusr Total | Paaiata ‘+ Kung ang mga magulang ay may hanapbuhay (employed) 0 di aya ay may sarling negosyo, magbigay ng kopya ng Income Tax Return (TR) 0 We2 para'sa taong 2017. ‘+ Kung walang hanapbuhay (unemployed) ang ama, magbigay ng kopya_ng BIR Certification © Muni Exemption ng pag file ng ITR. + Kung ang ina ay "housewife, hindi na kailangang magsumite ng nasabing sertipikasyon, ipalBarangay Certitication of Indigency 0 IIT. OTHER HOUSEHOLD INFORMATION Electric Consumption forthe last Three Months: oes you ary shave wa Loves" CINo uh ‘ keh hn CERTIFICATE OF ELECTRIC SHARING This isto certify that families are sharing in the payment of electric bills under the name of with address ‘They are paying the following amount ‘Amount fn poses) ‘Signature of | Cortiiod True and Correct: Name of Family Heads” Monti | Month? — Monih3_| Family Heads Prted Name & Signature of Barangay Ofical OnePreys Uk erat TO WHOM IT MAY CONCERN: This is to certify that has consistenty maintained good moral character, ne date of application nere having no disciplinary action taken against himvher as of Printed Name & Signature of PrncipallGuidance Counselor Date TO WHOM IT MAY CONCERN This i to certify that is a candidate for the Grade 12 graduation under the STEM Strand of the for the SY 2018-2019, Printed Name & Signature of Principal Date: ee ea ote e ete OLE ide ene oe ee eed TO WHOM IT MAY CONCERN, under the This is to certify that is a candidate for the Grade 12 gradu: ;duation for the SY 2018-2019 and is classified within the upper five percent of graduating class. NON-STEM Stran ted Name & Signature of Principal Dat ee aoe ase applicant has already graduated from i 2 previous year) TO WHOM IT MAY CONCERN: This is to certify that the undersigned has not taken any previous DOST-SE! Undergraduate Scholarship Examination and has not ‘any past secondary or u Printed Name & Signature of Printed Name & Signature of Parent or Guardian Date eee This is to certty that my sonidaughter, has no pending application for immigration tothe USA 0° any other country Ware o Aone Printed Name & Signature of Parent Date [rece pO Dads a ‘TO WHOM IT MAY CONCERN, is a bonafide resident of This i to certify that for not less than 4 years. “Printed Name & Signature of Barangay OffcaliPrnapal Date:FORM B — HOUSEHOLD INFORMATION QUESTIONNAIRE (HIQ) (Continuation) II. OTHER HOUSEHOLD INFORMATION (Continuation) ‘Ownership ofthe housing unt: Tees, Faw mur 6 te] enorized how much we Downed, Fully Pad Rented others, pls. specty ven ronmiranonse owned, Amortized ORent freefiving with relatives Does your family own agricultural land or non-residential land? Yes CNG yes st he ot area Does your family own vehicle's? CIVes CINo Type No. of working units | Year Model rex 2000 20 [Make ins nonsn Surun. Toyts) Tieycle Passenger vehicle (e.g. Jeepney. Van. etc) GariAUVISUV Truck’Bus PARENTILEGAL GUARDIAN CONTACT INFORMATION Permanent Address (ovseneNo. Simot LavBh. Vingearanaa7 Landline Phone No. Mobile Phone No. ‘Ciyttanicsality Zipcode [ ict Email address: SIGNED DECLARATION BY APPLICANT AND THE PARENTSILEGAL GUARDIAN: lie hereby cotly to the truthfulness and completeness of information provided. Any misinformation or withholding of information wil automaticaly disqualify myfour son’saughter from the DOST-SEI Science and Technology Undergraduate Scnolarship Program. live are also willing to refund all the financial benefits received plus the appropriate interest if such misinformation is discovered after myiour child accopted the awa In connection with this application for scholarship, Wwe hereby authorize the DOST-SEI designated representative to conduct a background check on the family's socio-economic status and to visit our family dwelling Moreover, liwe hereby express mylour consent for the Science Education Institute of the Department of Science and Technology (SEL-DOST) to collect, record, organize. update or modify, retrieve. consul. use, consolidate, block, erase or destruct my personal data as part ff mylour information. IWe hereby affirm mylour right to be informed, object to processing, access and rectify, suspend or withdraw my/our personal data, and be indemnified in case of damages pursuant to the provisions of the Republic Act No. 10173 of the Philippines, Data Pavacy Act of 2012 and ils corresponding Implementing Rules and Regulations Applicants Signature Over Printed name Date Signed Father's Signature 1 Mother's Signature , Legal Guardian's Signature Over Printed name © Over Printed name © Over Printed name For DOST SEI/RO Staff use only : Checklist of Documents Submitted Form A — Personal Information THIS APPLICATION FORM AND. Form B ~ Household Information Questiannaire (for RA 7687 Applicants only) ATTACHED DOCUMENTS WERE Form C ~ Certificate of Good Moral Character VERIFIED FOR COMPLETENESS BY Form 01 ~ Principal's Certification (Far Applicant from the STEM Strand Form D2 ~ Principal's Certification (Far Applicant from the NON-STEW Strand) Form E ~ Applicants Certification (If graduated from high schoo! inthe previous year) Form F — Parent's Certification (Ifo pending application for immgratio Prnted NameiSignature Form G ~ Certificate of Residency (For RA 7687 Anplicants only) Two recent (1"x 1°) pictures Date of Review of Document Photocopy of Birth Cerificate Parantis 2017 Income Tax Return / W2 / Employment Contract for OFW J BIR, Date of Retum of Applicant: Certificate of Exemplion fr Fling of ITR / Municipal or Barangay Certificate of Indigency (for RA 7897Applicants only) Elecine Bils for 3 consecutive months in 2018 {for RA 7687 Applicants only) A‘fidavit of guardianship (if wrth fegal guardian) Contfcate of scholarship in high schoo! (if appiicablo) High School Statement of Account (if applicable) Others:“ON wloyeonddy /OOL Aueotiddy jo owen (W8qe7 eigeyorieg) diysiejouss svenpesbiopun 9s 13S-1800 6102 (asoa Ag dn pony 24 03) thers and re will parse eaoers in he Fells inoe and echo age] eNat im STUDY PLACEMENT a riaray ey «Sti nrts Clogs 5) tam omen of SAT a,b rr al : te even oy na ie as pe I CHE ened Cents of Esolenee (COE) ot Centers of her home region, ard pretrbly alr hisher fil of specials Development (COD) for the SRT programe covered under tion, for 8 minienum period equivalent tothe length of time helshe | J] cec0st se trargation sbdosos cpeiteone, tr FAP Lan etn > shown By S&T Programs Covered Under the DOST-SEI Zee 2 = ad | OI rere reee) zeecize util anager npr SELLE LES, [eee fom ati mgr [eyed heeey 52588 25S [pmcmeecwnenn cm a Aid rw a Pamay een ga32355 Z| Bgeeese ye vnonsvangenons —— JOMDSE ME Vara Scarce nkwaton an Cormsiains | popy . ES28352 | and Engynsenng | ‘Tectnoiogy Science and Technology 263 e303 | [ome momen oman on an Undergraduate Scholarships zos esse ual ickemoeny Cammy Nation InomationTacracoy els logy 8 Hetero ESE SSE | [pemrcrniny comptr Engrestng| InmatonTechobpySysens | Nation azienak | itvalEcorarics Computer cence Insunertaton and Contolngg. | Nutréon and Dita BEES Sy | Protesters ee Co Pacoa Eo Fesge seg Manutacring Engineeing- eoeis Eecronis ns Conmunatens BSS S S25 — | |rocume pe mmunatone | nenagement ones! Phamacy (¢ye0r program) ; pedigdt | Ernesto renee | See Scholarships eegegee vial ence EnvonmentalSoerce Ms romacy mn ii gees? 3 | ee Boeke eV sans Es ee Sy = RA 7687 ge gee & 5 T [ages Pris Food Techrotegy Maine Sciene Payenoogy guiness rear Gas oa a e333 ¢ = “ato, Slay Ato St penser chr SE ZERE | [Npedmmcwn aria lr oeay —— Pca Soro en sry i ane 26heea0 ae toto toons pot eseed he etc vans eBeesia st Pnjes wn Ntrale etre eng, of cera eats. Ouest pase port ets BET gg gH | Yasietrmacswnvaas | occccmaeng atonats Chena pps Py Or aye bane sree, eget, ce old a aoa \ eee Seerce Sioogy and Cheri ‘clon, and sane and mafoats tating. 8 2235 2 | Vieasains cay a sna | tn ges & = = . BES | [psumentemon nal Ener aborts Teahng 26a 8 latent a ee ee “ne Bly Meche sora mur simon S25 LY [eens Eninecina navi Design Neca Laboraon Scenes | 2S Pagan The DOSE! Met Scholarship Program fore known agg gs te NSB or NSTA Schl under RA No 287 22 ¢ Genal pea nda Exghevng Neda Teawotyy tort b srs wih hgh apie sce rd Ses 3 88 F 3 2 2 3cas D. Examination Coverage A. General Criteria of El lity reer es serdsesrnat| y Eek) Pac terenesiyb te betas zee BoToova] : eo) he sof snares a spe! rowed by Pe OOST Seely nal and unszpedte uote olf 20165 Shoahp Darna 7 7 Se Ghcururke en Tuner eon POU pe seer en] #40 Ane ma sak arn may SAT press ne He OOS ep Fave Onc by S20 evel secede by FAP bre BT pens cowed under te DoSr Se Undgaat ray ns ewe Fro0Geerort| [he shoul passe ating exaninaton fr sain Toe unary whee ae Serer Anas fee a flrs toate ‘+ _Tulion and other schoo! feos [P%,500.03] ) An awardee shall comply with the terms of the Scholarship Agreement tn be entered into between himself + Boker BR oaBeeOR)] hese poor ey grin a! he 0091S = Monthly Alowance 2rrorts| needing clearance fom DOST forwarded tc the appropriale government agencyties for tracking Ce see) }in case of solsship quate who come Fom be nen STEW Stand class, they may ev ofthe vena eerarnee v v Slot efects he il snes 9 279200 ov ory a ey ae eed taryo” he SET Fon 8: Hae emai Ge Z , = Form C:Certcaie f Good Moral Character 7 Pe alee Fam DE entan al aaa bans Pe Seer Hh Sea] v +The span fom cane ele ale Sc aan Ii, nd Lie Snze Herne By STEM sens Class DOST Cmpd., General Santos Ave., Bicutan, Taguig City, Metro Manila; DOST Regional Offices; Provincial For 02. Cortina a alcat ens © be we Pe] 7 Sconce ard ecu Gris (PST) ohn of bw Cengeosan ad Seabee be NOW STEM ste rhe es gata se Sede stat est gph >For E: Suet of par alte has ret ak iy pov «soz lm canbe ttre Src ar nite, DOS Rona Oe PETC mare fam Sart pao tse en ew] y Deadline for Fling of Application Date of Examination: fom 6: Cisse este Z = August 31, 2018 October 21, 2018 Ts wen pees Z Z Proce) teh Coven Z Z «The Tes Pot sal ema he plea oe pip edo oe apa a Pa 2 ope Tx ee 27 Eoet Gan * fmf S08 ap On PSTC a re ones cnet =a le Beck secivonenbs WZ Z = ahd af P00 Deparment of Science and Techraogy Soe oy etch ost noe oes leach AD) Siitnce CoucaTIOn weriruTe eonchcatia an arate Soa SEASON CRSA] ‘ ALD sont and tees Soence ertage Big NOT ACEESTASE, The ee tne moray at Sou 4 Sp 2051 Compound, Genera’ Santos ve, Bloutan, Taguig Chy SENCEESUCATON NTE Contact noe (02) 859-0088 102657 33.837 207 ee 2582 DH vise. dostgor oh