Republic of the Philippines

Department of Science and Technology

PHILIPPINE SCIENCE HIGH SCHOOL – MAIN CAMPUS
Agham Road, Diliman, Quezon City

CONSENT FOR PUBLICATION OF RESEARCH PAPER

I, ____________________________________________ (complete name of student),

of Class 2010 of the Philippine Science High School – Main Campus

consent do not give consent

to the publication of my / our research paper entitled:
_____________________________________________________________________
_____________________________________________________________________
(Title of Research Paper)

I further agree do not agree

to assign the royalties / any amount paid by the publisher to the PSHS-Main Campus to fund
the school’s priority research projects.

Signature of Student: __________________________ Section: _____ Group # ___

Signed in Quezon City, on ________________, 2010

We, the parents/ guardian,

agree do not agree

_________________________________ ______________________________
Signature of Guardian/Father over Printed Name Signature of Mother over Printed Name

NOTE: Your responses on this form will NOT in any way affect your grade in STR2.