Application No. ____________ STSD-201.

3
Rev. 3 / 02-21-22

DEPARTMENT OF SCIENCE AND TECHNOLOGY

SCIENCE EDUCATION INSTITUTE
Bicutan, Taguig City Attach here
1 recent passport
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APPLICATION FORM

CAPACITY BUILDING PROGRAM IN SCIENCE AND MATHEMATICS

EDUCATION (CBPSME)

School Term: [ ] First [ ] Second [ ] Third Semester/Trimester

Academic Year ___________________

Form 1. Information Sheet

I. PERSONAL DATA

1. Name of Applicant: ___________________________________________________

Last Name First Name Middle Name
2. Sex [ ] Male [ ] Female 3. Age _____ 4. Nationality _________________

5. Permanent Address:__________________________________________________
No./Street Village/Barangay Congressional District

__________________________________________________
City/Municipality Province Zip Code Region

6. Residence Phone No.: _______________ 7. Mobile Phone No.: ______________

8. Email Address : __________________________________________ ____________
9. . Date of Birth: ________________ 10. Place of Birth: ____________________
11. Civil Status: _________________
If married, Spouse’s Name: _____________________________________________
Occupation: _________________________________________________________
Business Address: __________________________________________________
__________________________________________________
Phone No.: _____________________ No of Children:_______
II. EDUCATIONAL BACKGROUND

LEVEL SCHOOL DEGREE YEAR GENERAL HONOR/S

EARNED GRADUATED WEIGHTED RECEIVED
AVERAGE
(GWA)
Baccalaureate

Master’s

Title of Thesis

Baccalaureate

Master’s

III. EMPLOYMENT DATA

1. Present Employment Status: ( ) Permanent ( ) Contractual

( ) Probationary ( ) Self-employed
( ) Unemployed
1.a If currently employed

Position: ________________________________ Length of Service in Years ____

Name of Institution: ___________________________________________________

Address of Institution: ________________________________________________

Email Address of Institution: ____________________________________________

Telephone No/s: ______________________________________________________

Name of Head of Institution: ____________________________________________

Official Designation of Head of Institution _________________________________

2. Employment History
• If employed by the Department of Education (DepEd), please accomplish Form
2A.
• Please attach copy of Service Record/s or Certificate/s of Employment.

NAME OF INSTITUTION/COMPANY DATE OF EMPLOYMENT POSITION

IV. CAREER PLANS
Write in the attached sheet (Annex A).

Discuss your future plans after graduation.

V. DOST-SEI SCHOLARSHIP PROGRAM INFORMATION

If you have previously availed of any of the DOST-SEI scholarship programs, please
indicate below:

Scholarship Program Year of Degree Program/ Year

Please check Award Completed
Merit
RA 7687
Project 8102 Ed/9001 Ed
JLSS-Merit
JLSS-RA 7687
JLSS-RA 10612
Faculty Development Program for
Teacher Education Institutions (TEIs)
ASTHRDP-Science Education
CBPSME
STRAND

VI. SCHOLARSHIP INTENTION

1. What type of Graduate Scholarship Program are you applying for??

[ ] Master’s [ ] Doctoral

2. Field of Specialization: __________________________________________

(Refer to the brochure and specify)

3. Indicate the university where you intend to enroll in (You are advised to seek
admission at the university where you intend to enroll in.):

______ Ateneo de Manila University

______ Bicol University
______ Central Luzon State University
______ Cebu Normal University
______ De La Salle University
______ Leyte Normal University
______ Mariano Marcos State University
______ Mindanao State University-Iligan Institute of Technology
______ Mindanao State University-Marawi
______ Philippine Normal University
______ Saint Mary’s University
______ University of San Carlos
______ UP Open University
______ UP Diliman College of Education
______ Western Mindanao State University
______ West Visayas State University
 4. Have you been admitted to the Graduate School at any of the identified universities?

[ ] Yes [ ] No

5. Intended start of program of study:

[ ] First Semester [ ] Second Semester AY _____ - _____

6. For Lateral Applicant:

6a.
Total Number of Required Units in Your Program
Number of Units Already Earned
Remaining Units to be Taken
General Weighted Average
Please submit Certification from the university indicating the following:
• number of graduate units required in the program
• number of graduate units already earned with corresponding grades

6b. Have you started working in your thesis/dissertation? [ ] Yes [ ] No

6c. If your is Yes in #6b, has your research topic been approved by the panel?
[ ] Yes [ ] No

If your answer is Yes, please attach the Approval Sheet and the Timeline of
your research activities.

6e. Thesis/Dissertation Topic

______________________________________________________________
______________________________________________________________
______________________________________________________________

6f. What DOST priority research thrust is your research topic aligned with?
Explain how.
_____________________________________________________________________________
_____________________________________________________________________________
_______________________________________________________________
_______________________________________________________________

VII. RESEARCH INVOLVEMENT

1. Research conducted in the last 3 years. Use additional sheet if necessary.

AREA AND TITLE OF LOCATION/ FUND NATURE OF

RESEARCH DURATION SOURCE INVOLVEMENT
 2. Discuss your proposed topic/research area/s of interest for your
thesis/dissertation. Use separate sheet (Annex B).

Note: The research proposal must be aligned with the priority research thrusts identified in the
DOST Harmonized National Research and Development Agenda (HNRDA). Refer to the
DOST website, www.dost.gov.ph

VIII. PUBLICATIONS
Use additional sheet if necessary.

TITLE OF TECHNICAL TITLE DATE NATURE OF

PAPER OF PUBLICATION PUBLISHED INVOLVEMENT

IX. AWARDS AND RECOGNITION RECEIVED

Use additional sheet if necessary.

YEAR OF
TITLE OF AWARD AWARD GIVING BODY
AWARD

X. TRUTHFULNESS OF DATA/DATA PRIVACY

I hereby certify that all information given above are true and correct to the best of my
knowledge. Any misinformation or withholding of information will automatically disqualify me
from the program, Capacity Building Program in Science and Mathematics Education. I am
willing to refund all the financial benefits received plus appropriate interest if such
misinformation is discovered.

Moreover, I hereby authorize the Science Education Institute of the Department of

Science and Technology (SEI-DOST) to collect, record, organize, update or modify, retrieve,
consult, use, consolidate, block, erase or destruct my personal data that I have provided in
relation to my application to this scholarship. I hereby affirm my right to be informed, object
to processing, access and rectify, suspend or withdraw my personal data, and be
indemnified in case of damages pursuant to the provisions of the Republic Act No. 10173 of
the Philippines, Data Privacy Act of 2012 and its corresponding Implementing Rules and
Regulations.

_________________________________
Signature over Printed Name of Applicant

_________________________________
Date
Application No. ____________

Form 2A CERTIFICATE OF DEPED EMPLOYMENT AND PERMIT TO GO ON STUDY

LEAVE (For applicant who is employed by the Department of Education)

This is to certify that Ms./Mr. _____________________________________,

an applicant of the CBPSME scholarship program, is a permanent employee of the
Department of Education for _________ years.
(no. of years)

Should she/he qualify for the scholarship, she/he will be allowed to take a
study full-time for a period of two/three years while on scholarship.

______________________________ _____________________________
Principal Schools Division Superintendent
______________________________ _____________________________
Name of School School Division
Date _________________________ Date _________________________

_____________________________
Regional Director
DepEd Regional Office No. _______
Date _________________________

Form 2B CERTIFICATE OF EMPLOYMENT, AND PERMIT TO GO ON STUDY LEAVE

(For applicant who is employed by private school)

This is to certify that Ms./Mr. _____________________________________,

an applicant of CBPSME scholarship program, is a permanent employee of under
the ________________________________________________________________.
Name of School/Institution

Should she/he qualify for the scholarship, she/he will be allowed to take a
leave of absence from work and be released from institutional responsibilities to
study full-time for a period of two/three years while on scholarship.

___________________________
Principal
____________________________
Name of School
Date __________________________
Application No. _________

Form 3. MEDICAL CERTIFICATE

__________________________
Date

TO WHOM IT MAY CONCERN:

This is to certify that I have examined _____________________________ and found

(Name of Applicant)
him/her to be physically and mentally fit to undergo graduate studies.

This certification is issued in connection with his/her application for scholarship under
the Capacity Building Program in Science and Mathematics Education.

______________________________________
Name (Print) and Signature of Licensed Physician
PRC License No. __________________________

Health Agency______________________________________________________________
Address _________________________________________________________________

CHECKLIST OF DOCUMENTS TO BE SUBMITTED

Accomplished Application Form (Form 1)

Certificate of DepEd Employment and Permit to Go on Study Leave (Form 2A); OR Certificate of Employment
and Permit to Go on Study Leave Form 2B)
Medical Certificate (Form 3)
Birth Certificate (Photocopy)
Certified Copy of the Official Transcript of Records (TOR)
Certified True Copy of Service Record
Notice of Admission to Graduate School in any of the NCGSME member-universities
Career Plan (Annex A)
Career Plan (Annex B)
Endorsement from Former Professor 1
Endorsement from Former Professor 2
Commitment to Complete the Degree
Valid NBI Clearance
Letter of Nomination/Recommendation from the Head of the School/University
Approval Sheet of Thesis/Dissertation Research Topic
Timeline of Thesis/Dissertation Research Activities
For lateral entrant, certification from the university indicating the following:
• number of graduate units required in the program
• number of graduate units already earned with corresponding grades
Application No. ____________

CAPACITY BUILDING PROGRAM IN SCIENCE AND MATHEMATICS EDUCATION

Annex A

Name of Applicant ___________________________________________________

Type of Scholarship Applying for [ ] Master’s [ ] Doctoral

Date _______________________________________

CAREER PLANS
In not more than 500 words, discuss your career plan after graduation from your master’s/ doctoral
degree.