REGION TO BE REPRESENTED:____________________
Surname: ____________________________________ Gender: [ M ] [ F ] Height: ______________ Passport-sized photo

First Name: ____________________________________

Middle Name: __________________ Weight: _________ Age:__________________ Nickname: ___________ Birthdate: _______________ Birthplace: ______________ Official Mailing Address: __________________________________________________ ____________________________________________Zip Code: _______________

Residence Address: _____________________________________________________ Tel. No. (landline/Area Code): _____________ Mobile No.:_____________________ Email Address: _______________________ Religion: ________________ Present Occupation/Position: ____________________ _______________________ Pls. Indicate date taken

Name of Office or school: ____________ Office or School Address:_______________ Years in the Present Work: ______________ Civil Status: _____________________ Father’s Name: Place of Birth: Occupation: Mother’s Name: Place of Birth: Occupation: No. of Brother/s No. of Sisterr/s Educational Background Name of School/University Course / Inclusive Dates Elementary Secondary Tertiary Vocational Post Graduate Scholarship Grants Donor Inclusive Dates

Honors Received

Honors Received

Youth Organization/Youth Serving Organization Affiliations: Name of Organization Position

Years of Membership


Special Skills or Talents: Food Restrictions: Dialect(s) or Foreign Language(s) Spoken: Do you have a passport already? Yes ____ No ____ If yes, what is the number __________________ Expiry Date _______________ If not, have you applied already? Yes ____ No ____ If yes what is the status of your application? _____________________________ Title of Seminar/Training Course Attended Inclusive Dates Allergies

No. of Hours

Conducted by

Previous Work Experience Name of Company Position Inclusive Dates Salary

Character References: Name

[not related to you within the third degree of consanguinity] Occupation Address and Telephone No.

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year and source of fund NYC Personnel: ________________________________ (Name of NYC personnel) Others [pls. One (1) original copy of the Certificate of Residency issued by the Punong Barangay where the applicant is residing 4. Escario St.Oct. school or residence. must have a strong background in Philippine history. One (1) original copy of a certification from the organization that the applicant is an active member for at least two (2) years immediately preceding the application period. must be residing in the region to be represented for at least two (2) years immediately preceding the date of application. LUZON Room 15. No. 28 . please state nature of service and how long [ ] Yes If yes. please indicate the nature and status f yes. Davao City . 2013 NOTE:  Non-extendible deadline for submission of application form is 5:00 o’clock pm on April 12.All facts and data given in this information sheet will be treated with utmost confidentiality Please name any SSEAYP Alumni you know Relationship Have you previously applied for SSEAYP?  No  Yes How did you know about the program? Newspaper: _____ Radio: ______ Magazine: _____ TV Ads: ______ How many times? Have you been a participant of any NYC International Exchange Program? [ ] No [ ] Yes If yes. Ms Rhenelyn Dadulo Mr... Application form with the requirements may be submitted through sseayp40@nyc. cruise (Oct. Lack or non-compliance of any of the above stated requirements will mean automatic disqualification without notice. No. on or before April 12. please indicate the program and year [ ] No [ ] Yes If yes.16) and post-program evaluation (Dec..  The National Youth Commission reserves the right and prerogative to exclude applicants who will not meet the minimum requirements of the Program. Tel. the applicant must be working in the region to be represented for at least six (6) months immediately preceding the date of application. 9. 16. Japan and the other ASEAN countries preferably first time international traveler and or must not have been a a. Number: ____________________ Date and Place Issued: _________________ Qualifications: 1. 7. Hotel Legarda Ground Floor No. Passport must be valid until April 25. 2013 Sept. Magsaysay Ave. Must have served the youth sector as an active officer or member of a youth or youth serving organization for at least two (2) years immediately preceding the date of application Filipino citizen. he/she must present a certification duly signed by the head of the organization that the applicant is actively participating in the region’s youth-related activities for at least six (6) months immediately preceding the date of application. 2013 13. I further declare that any information given by me that is untrue may constitute a ground for expulsion in the SSEAYP and prosecution for perjury. Requirements: [ Please submit only the required documents] 1. wherein round-trip airfare. please indicate Have you availed of any program or scholarship grant offered by the Japanese government? [ ] No Have you attended any seminar. if at the time of application. Magsaysay Mr. 074-6190511 Taal Ave.28-Dec. at least two (2) years immediately preceding the date of application. and Must be willing to take a leave of absence from school or work and complete all trainings and activities before. if not employed or nor studying. must be between 18-30 years old as of April 1. Field Office IX. Suazo St. Quezon City. I will join the activities of the program such as Predeparture training (July 16-25). F. please specify _____________________________ SWORN STATEMENT I hereby certify upon my honor that all facts and information indicated herein are true and correct to the best of my knowledge. wherein round-trip airfare was shouldered by the participants. Naga City Youth Baguio City Center Bldg. Raymond Domingo D. Indicate]: ____________________________ Have you rendered voluntary service for the NYC? ? [ ] No [ ] Yes If yes. 11. _____________________________ Signature Res. Naga City Mail or hand carry your application to Ms. original and not scanned. No. Marielou A. no other attachments) 3. please indicate the program and year [ ] Yes If yes. No. please indicate the Program. Must be willing to be an NYC volunteer after the please indicate details [ ] No [ ] Yes Do you anticipate to take part in any program. please indicate Have you ever been convicted of any crime involving moral turpitude? [ ] No Do you have any pending civil and administrative case? [ ] No [ ] Yes [ ] Yes If yes.17-19). conference or trainings abroad? [ ] No [ ] Yes If yes. IN WITNESS hereof. 12. 28-Oct. I subscribe and agree that the National Youth Commission has the sole prerogative to select. 4th Flr. are you willing to enter into a MOA with NYC to render voluntary work for its programs and activities? Have you joined or attended any SSEAYP activities? [ ] No [ ] Yes If yes. The undersigned expressly authorizes the National Youth Commission or its representatives to use. Must be willing to craft a policy paper to be submitted within one hundred (100) days from end of the program. Chua. Before the date set for the submission of application. NYC AREA OFFICES VISAYAS MINDANAO 5/F B. 2013. b. Eddie Cuaresma Mr. the Paper Screening Committee reserves the right to determine the applicant’s regional representation If a student wishes to apply to represent a particular region. Cert. Further. pre-departure activities (Sept. share and process personal information that I have provided. Date accomplished:______________ 8. 2013. Have you been involved with any NYC local program or activity? [ ] No If no. Bookman Building. grantee or recipient of any NYC-coordinated international program. must not have been charged before the prosecution’s office or convicted of a crime involving moral turpitude physically and mentally fit to travel must be residing at the place of representation for at least six (6) months at the time of application a. Telephone No. cor. board/bar exams or scholarships this year? Are you on a scholarship granted by the Department of Science and Technology (DOST) and/or any other government agencies? If yes. reclassify and nominate the delegates to the Ship for Southeast Asian Youth Program [SSEAYP]. Pre-departure Training Pre-departure Activities Cruise Post-Program Evaluation July 16-25. One (1) copy of application form with passport sized photo. geography. 27. please indicate the nature and status (you will be required to present clearance). 02-4162833. at least one (1) year immediately preceding the date of application 5. 373 Quezon Avenue. single. the applicant must be studying in the region to be represented for at least six (6) months immediately preceding the date of application. If a student.Dec. 28 . Veterans Ave. Armando Angeles Jr. And if chosen. 4.. b. Davao Area Office. Tel. culture and arts must be knowledgeable on current issues about the Philippines. grantee or recipient of any NYC-coordinated international program. 10. shared or declared in this form/document/site for any lawful purpose. Building 2/F Marell Building 3/F Atilano Bldg. during and after the program: 6.. 032-2689531 Tel. National Youth Commission. food and accommodation were borne by the organizer/s. Old N. 2013. 2. Photo should have a white background. please indicate the program(s) and year.. 088-8575895 Tel. 17-19. 27). ARDS Room. 2. the applicant has less than six (6) months of stay in the workplace. Bldg. 2013 Dec. If employed. 12. One (1) copy of the applicant’s resume (maximum of 3 pages only. 062-9924851 R. 2013 Oct. Cebu City Cagayan de Oro City Zamboanga City DSWD. I am executing and signing this statement voluntarily without compulsion. [ ] No Do you have any physical disability? [ ] Yes. and its decision is final and executory. Legarda Road. 3. Tiano-Gomez St.

Julius Gutierrez .Tel. No. 054-4730435 Ms. Nydia Paladan Please fill up the form legibly Mr.

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