See Republic of the Philippines erry [ rt | Pry s Department of Science and Technology a - Nor FOR SALE 2017 Total Annual Family Gross Income: SCIENCE EOUCATION INS TINUTE: canbe REPRODUCED (Tocobio & Nonsaradie) P.O. Box 18 Taguig Post Office ALENTRESSIONATURE IN ‘THIS FORM MUST BE ORIGINAL ‘Aug, Electrety Consumption for 3 months ‘Annual HS Net Tution & Other School Fees: 2019 DOST-SEI Attach recent Saas Aspe asec ee SCIENCE AND TECHNOLOGY xi" A RA 7687 UNDERGRADUATE SCHOLARSHIPS photo here MERIT —P200.000.R. No.__ APPLICATION FORM Once officially stamped, ee 'DO NOT detach photo, Printed Name/Signature | Deadline for Filing of Application: August 31, 2018 ‘Attach another copy to. ;chedule of Examination : October of the same 1” x 1" photo se OST RO. Ne ‘Schedule of Examinati October 21, 2018 the sane 159° eee Instucton: Wile cleaty in the Box provided or check the box forthe appropriate answer. Avold erasures. For any erasure, the applicant should countersign the item conscted along the page margin. PLEASE ANSWER ALL ITEMS. 1. PERSONAL DATA [Name of Applicant (a: Name, Fst Nam, Mie Name, Sufix Nar: Assessed by: Date of Binh mwoorvry; | Place of Birth ‘Number of Children in the | Birth Order of Applicant 7" chs 2* chi ot): pop Family Sex Mobile Phone No: Email address: Citizenship OMale Female Permanent Address (Housel No, Soe! Loli VilogaBarangay) Bayou ai Tye: leare ape Dyes ONo Ciyntlspaly Prous: peade Disa Have yeu bean esued.a | yes, wnte the Pasopot No, passpor? Qyes _ONo Type of Schoo: ‘Senior High School Strand CiraguarPunics — CiscanceHs Cl Prvstetis 1 UniertyCalege based Senor HS Cistem —CINON-STEM Name of Schoo! “Tuition and Other School Fees Paid in a Private High Schoo! e. ‘Address of Schoo! 1 FAMILY DATA Legal Guardian Fathor Mother saws pare re Gosoase working Suatonch) Name Highest Educational Attainment Occupation 1 specty Name of Employer Employer Address 2017 Annual Gross Income linpasos taxable and no tvab) If selfemployed, declare 2017 ‘Annual Gross Income Is your household included in the DSWD Listahanan 2.07 Yes CIN [yes place provi clear photocopy of your DSWD) |s your family a beneficiary of the DSWD’s Pantawid Pamilyang Pilipino Program (4Ps)? OYes ONo [ity plese prose ler polacopy of your fomiy« 42s) TIE SCHOLARSHIP INTENTIONS DATA’ eck peep bx er acholaaip pera pod fr RRA 607 SCIENCE AND TECHNOLOGY SCHOLARSHIP 11) Fer pecan who belongs to famly whose socio-economic status doesnot exceed these values of ALL the identified Indcaors 3s Spprved bythe Aavtory Conte on ST Scholarships DOST-SEIMERIT SCHOLARSHIP [| Fer'an spptcant who belongs 1 a famiy whose socio-economic status exceeds the set valves of any ofthe identi indicator, Applicant must pay 2 non‘etundable esto of 200.00RENCE nk re) I, HOUSEHOLD PROFILE Prof of household members (Please include only the parents, applicant and applicants sibings who are single, age 21 and below, ive under the same root {and share in common food) / (slang ang mga magulang, aplikante at mga kapatid ng aplkante na walang asawe, may edad 21 pebaba, kasalukuyang aka sa bahay at kasama sa iibahaing pagkai.) ‘Name Rolationship| Age] Civil | Highest | Grado or Year | Occupation of | Class of | Gross Income (Pu Housohokd Hoa as fst in tho tinue | to Applicant | | Status | Educational | Attending it | Working | Worker | for the Year name of apceand (See | Attainment | Currentlyin | Household | (Sco. | 2017 in pesos) cades | (Speciyarace, |” School Member | codes betom | year or ceyre0) elon) o a lo! | © o ® o 1 2. 3 4 5 6 7. 8 3 “Tousehal ad usualy rons he che sauce of come athe arly. He o shes espansibe fre orgaiaton and care of fhe hovsahal or the person uh ls regarded as such by be mombars oo household. Total: ‘Codes for Column 4 tt tts) ‘Codes for Column 8 case of woke) Ssage 1A Wore fo pat househols E- Erpoverin own family operated farmiusinees Me hamieg 13 Works fo prea extabishment F Woe sth pay on ow tiyeperte fanusiness Wwe (B= Wort er governed soereyteporaion {G=Worswiheut pay on own farsy-operates 1D DvorcedSaparato 1D Softempleyed winet ary moves (o., sar-sar ‘rmbusnece O=Unenoun Str onner crosenater H-Unemployed fo. housowt) JTL FINANCIAL CONTRIBUTION both parents are unemployed, do you have any relatve/s other than those in the profile of household members (whether here or abroad) who contnbute in ‘meeting your famly and school expenses? CIYes No Purpose of Financial Contribution Relationship of Contributor to Applicant | Frequency of Contribution | Annual Contribution (e9. educatona assistance) [291 bathor whois an OF) (see todos bal) (inpesos) ‘Codes for Golumn 3 (Frequency of CorrbutonisA=Wonthy 8 Guartery G-SeriAnmval O-Annval €—iequer | Tota ‘Total Annual Household Gross Income 2017 (1. Household Profile + II. Financial Contribution) ‘= Kung ang mga magulang ay may hanapbuhay (employed) 0 di kaya ay may sariling negosyo, magbigay ng kopya ng Income Tax Return (TR) @ W-2 para sa faong 2017. ung walang hanapbuhay (unemployed) ang ama, magbigay ng kopya_ng BIR Certification o Municipal/Barangay Certification of Indigency 0 | Exemption ng pag file ng ITR, TIT. OTHER HOUSEHOLD INFORMATION. Electric Consumption forthe last Three Months: Mon Monn? on 3 Bo wh kwh kwh rye pease sccompish the Cette of Electric Sharing CERTIFICATE OF ELECTRIC SHARING This isto certify that. {families are sharing in the payment of electric bills under the name of te offaies shang) with address They are paying the follwing amount ; “Amount (n pesos) Signature of | Certfed True and Correct: Seeueisteemeed eames Month | Month 2 | Month | Family Heads ees] ‘rinted Name & Signature of Barangay Ofidal Date! ESS WT RIES as apOTESOTS BTRee RR eens TO WHOM IT MAY CONCERN: This i to certify that has consistently maintained good moral character, se oT Appa there having no disciplinary action taken against hiner as ofthe date of application. Printed Name & Signature of PrncipalGuidance Counselor Date: to avard of to shaarship sha caus fa once ql PNPM sek nte ee Wee de TO WHOM IT MAY CONCERN: therot. DOST-SE! may require anatorcoiaton bef tho signing of he This is 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: Re ea Rap OE Ne ee ede ee) TO WHOM IT MAY CONCERN: This is to certify that, is a candidate for the Grade 12 graduation under the a fsa NON-STEM Strand graduation for the SY 2018-2019 and is classified within the upper five percent of ‘graduating clas. NOTE: Please coty based on apote (ie. tp Sethe ass) academe standing as of grade 14 Printed Name & Signature of Principal Date: erase (incase applicant has aready graduated from sonior high schoo) ‘TO WHOM IT MAY CONCERN: This is to certify that the undersigned has not taken any previous DOST-SEl Undergraduate Scholarship Examination and has not learned any post-secondary or undergraduate units, Attested by: Printed Name & Signature of Applicant Printed Name & Signature of Parent or Guardian Date: eee OO This is to cerfy that my son/daughter has no pending application for Immigration to the USA or any other country, ‘are of Appice Printed Name & Signature of Parent Date: rd TEER NM Cn BA TO WHOM IT MAY CONCERN This is to certify that is a bonafide resident of fornot less than 4 years Printed Name & Signature of Barangay Offial/Principal DateTE ee Oa eRe LEON NO Coen II. OTHER HOUSEHOLD INFORMATION (Continuation) ‘Ownership ofthe housing unit rend tow rah te] among, tow mich te Clowned, Fuly Paid Rented Coothers, pls. specity " : Clowned, Amortized GRent freefiving wih relatives Does your family own ag7cutural land or nonresidential land? Vee GN Tye was Be ss sm oes your family own vehicle's? ClYes CINo Type No. of working units | Year Model jax 2000 2008) | Make (ox Honda Sunil Toyo) Tricycle Passenger vehicle (6g. Jeepney, Van, eto) ‘CariAUVISUV Truck/Bus PARENT/LEGAL GUARDIAN CONTACT INFORMATION Permanent Address (owe/at No. Ses, Lavi, Vitga/Barngay) Lanatine Phone No, Mobile Phone No. ‘cyanea: Provnoe: Zpcode Distt Email address: SIGNED DECLARATION BY APPLICANT AND THE PARENTSILEGAL GUARDIAN: Ie hereby ceriy to the truthfulness and completeness of information provided. Any misinformation or withholding of information will automaticaly disqualify myfour son/daughter from the DOST-SEI Science and Technology Undergraduate Scholarship Program. liwe are also willing to refund all the financial benefits received plus the appropriate interest if such misinformation is discovered after mylour child accepted the award. In connection with this application for scholarship, live 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, we hereby express my/our consent for the Science Education Institute of the Department of Science and Technology (SEI-DOST) to collect, record, organize, update or modify, retrieve, consul, use, consolidate, block, erase or destruct my personal data as part (of mylour information. IWWe hereby affirm my/our 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 Privacy ‘Act of 2012 and its corresponding Implementing Rules and Regulations. Applicant's Signature Over Printed name Date Signed Father's Signature or Mothers Signature or Legal Guardian's Signature (Over Printed name Over Printed name (Over Printed name Feed ta atte atc) Form A ~ Personal information THIS APPLICATION FORM AND Form B — Household Information Questionnaire (for RA 7687 Applicants only) ATTACHED DOCUMENTS WERE Form C — Certificate of Good Moral Character VERIFIED FOR COMPLETENESS BY: Form D1 ~ Principal's Certification (For Applicant from the STEM Strand) Form D2 - Principal's Certifcation (For Applicant from the NON-STEM Strand) Form E — Applicant's Certification (If graduated from senior high school) Form F ~ Parents Certification (if no pending application for immigration) Printed Name/Signature Form G — Certificate of Residency (For RA 7687 Applicants only) Two recent (1"x 1") pictures Date of Review of Documents: Photocopy of Birth Certificate Parent/s 2017 Income Tax Return / W2// Employment Contract for OFW / BIR Date of Return of Applicant: Certifcate of Exemption for Filing of ITR / Municipal or Barangay Certincate of Indigency (for RA 7687Applicants only) Electric Bills for 3 consecutive months in 2018 (for RA 7687 Applicants only) Affidavit of guardianship (if wth legal guardian) ‘Certificate of scholarship in high school (if applicable) High School Statement of Account (if applicable) Others:' : ll s! z BQlo esenn Zl aCe CR CUR un sul) 2 8 Bi eee 2 z zo} Terie eeu EL es Bee ferrtiee ee gz Gs 182 E Eso Gy [eommcunom crenny asi Menogenen ETSY | tage Engen g1eeF8e5s 2 PSS ei ce ee ee a BS gelscgess Ld I Q sae GI 5 Foe oe eg OT [aitucnecotanagenent [Chen wth ater Sconce [hfomston and Conmanstors Tyee A ¢ : 8238 ag 3 : io 0 and Enginarng Technology = Science and Technology 2 sei a? cultural an jms i Bol oesesks | [Simm cr Ennosieg formation Sytem ica Enosing Undergraduate Scholarships a aSeeees B 1 SOS EES ES | [apmsoecmnr [Comma ibmato Teo Var Bey & Bees Lee EE ETE | [tmacoman Camp rain nomaton Teeny Stns [Wan @ | eRe xq BI [Axteutwaleconomes ‘Computer Science Inarumenaton ané Convo Eng’, Nuiton and Dies $ LER eS EF | lpotanleorenn Dacor of vena edane | Le Sones Postar Eros He ee ypes o e| 2 1 8besesh 1 Eaton ns Conran | Henfcsn Ernie “ , s LESSEE | |pvcme EectonesmCanmaicatons | Yeap Somme Pama (48a . 8 1 eedszee | romero Ene | ew! Scholarships z (ogesees | Metta gees nc in Cal oe ae Erwenertal ence Nesgeret eros ond | Pam@n nln Cina, s igehade | a = RA 7687 = 1eeeeee 3 1 [Avoid Matematos Fisheries Maine Biioay Prhysis| 3 4 2 gs <3 | [Ate Piace Food Techrlogy Maine Seen Pacha? Repubic Act No. 7687, eo Inawn asthe “Scene and 8 288255 7 ‘evgy Soin Ate 1 pres trv 3 Ve RGEEE G | [ieeimmewmicd lhoey tia irony Pc ea Soot Pho an nevig ais vace eee 1eeeaseia | = Seok econo tats ot enced the st cut vals oom c ‘Scien Tesching (Biology, of ceran ators. Qualifiers must pursue pron fis 1 BSL g SE | [esr wmme cee couy abate Gren Pps Pps Stay nn tae womens egress 1e°8ea"e 1 Scena ogy and Gos) scence an ous an matenats iy, VR FFs 2 I [rveasuttes eotay Natbemats end Since Teating | Sates 1 BEE ge! lim ieniy [tation [rats os 1 See 2 | [esensny Heath Science esha Engestng 1 zs 3 & | [Boo Human Bolay shaves Engheeng “au Stem ony é o alt 35 g | Ceraics Engineed industial Design Medical Laboratory Soiance 28S Progam ‘The DOST-SEI Mert Solarship Program, frmedy known i Bags 3 i] —_ = = ee ‘83 the NSDB or NSTA Scholarship under RA No. 2087, is. 1 S22 EI [cencacmnene Tut Engoang Net Teeroy tard b sens wh hh spe sonen nd 1 gse oil matemates andar wing o pursue carer i the fds I 838 Z I of science and technology. Bo so leet al eh | 8 2 i! i 8 Fame STUDY PLACEMENT OARS 1 g | | 2 2 | [+ san uineniee a cts 00) Bee saraebiliai petere ie 3 ‘eum ee th coy on a tin bapa i ! : J + cco tenses contest cae (00): Cones Spapaeve easier ! zg |] 2eetpnet 600) rte S87 pra covered unr spectator # rnin pte equal eng a ! 1 J] ecostsitnrpatut sehoangs icraneabeiasteaon | 1 Ae isto tn Fa8P Lott Acostaton 1 1 7 :GEST > nara bam Fg Seen, v v > poor teed and desaring ent wh boengst aay whose wc] : ermenber fhe op ve pacer mi sts os teed fe stabs cheat dare ofthe Non STEM eran snr ih Shoo gadung css o© v v _rmember ofthe STEM stand senor school graduating cass reiterate munialiy rhe st years as ats by he bararaay] . haimon eet ood rl charac ard hood es 7 7 ater oft 2079 SAT SehlarstipExamineton v 7 EXScioneu kena son adobe shoo es 0.00 per Reade Ya Book Alone 100000 eye SPE win (Sonesta Ft Yor on 00000 [cup sence Pen Transprtaton lovarc (those shin ous frame rome) Ment Lrg Alone Sarna Alowarce frguted prea) Tesora. dase rand oe 700000 per mon + Tina oer coal eee 1.50000 = Beck Alnanoe 50000 fo stmt OF) = Nest Alone ron [Gataton cating alowance 700000] Cases [Form A: Persoal imation v v Form Housel eatin Questor v * [Form : Cate of Good ral Character v v [Form Di: Cafeaton tat apleant bongs b be senior high eco] y STEM sand Class [Form 02: Coricaton tat appicant belongs te upper 5% of Be] ei NONSTEM srandsenorigh cal graduating dass [Form E: Sateen of appcant tat hehe has not len any previ] DOST-SEI Unies Scflastip Examination and any undead] a Uns or past secondary couse fn cas aplcant fas akvady gradual fem snerigh schoo) [Form F: Sateen of part hat appa as ro pending aptoton el immiganta anyother county v v [Form G: Cena of Resncy v * >To oxen peas 7 7 = Phiocony ot Crate v 7 [Paes 2017 name Tax Ret | W2/ Enplorrent Contactor OFWH| x BIR Cat of xarptan fom Fng of TR By. Caf ndgerey [Ete Scones mentsin 2016 v * > Nonfat fo of 20000 ' SElcan ony acep cash, petal money ones, ogre bart carted castors and rarapers checks, PERSONAL CHECKS ARE] v NOT ACCEPTABLE. The paee of he money crar shoud be SGIENCE EDUCATION INSTITUT D. Examination Coverage Ths scholarship examination & desgnd fo mossu sites tht detomine scademic ard presser success Instone, chology, engoeng. and matematcs. The test incudes te folowing domans Legeal Ressonng Egle, Soenc,Natemses, Mechanical-Tecntal and a Sel-ivenory pa Rrra) The ards shall be sloced onthe bass of hr poromance ihe 2019 SAT Underraduat Scholarship Exainaion. eee The tof aardee as approved an announces bythe DOST Secreta fra ard unappesate, G. Terms and Conditions 8) An suarde must seek anion n ny SBT programs covered under the DOST-SEI Underatual Schoarshpsin any oft olwig: 21 State univrstes and caloss. 22 Tear netions enol as Canes of Excolenc o Contes of Development by CHED or Lve I sored by FAAP forthe S&T programs covered under the DOST-SEl Unceradute 3 DOST-Sel dented ete nsbstons Hehe should pass the qualivng exaninaton for adission fo th univarly whore Helshe ans to enol. » fret len fs Sipps oe we ieee g Sacco tate ee can am ty my lo Pa an ee + The apleston tom canbe cine at te SdenceEdueabon sre, 2nd Lew, SlenceHertoge Bl DST Gnpd. Gare Saros Ave, etn, Tapu Gi, eto Mania: 0ST Regina fies, Prova Sence and Tecnology Certs (PSTC) or Ofices ofthe Congressmen and Sento. can be ovmaded at ewe dost ge ph + Accompised fom can be fled he SeneeEdveston Ie, or DOST Region OFS=PSTC nearest the apseants soo or hare ales, 1 for Filing of Application: August 31, 2018 Dea October 21, 2018 + The Test Perit shall be mald to te applcans school principal fr dstibon to the applicants. case the les gent sno reed win he week belo theexainaton day, the appeant may hare ‘fom he DOST Regional os /PSTC and chck the neces designated st cerry befor he cnaminaton, Deparment of Science and Tecnology SCIENCE EDUCATION INSTITUTE ALD ‘sisnsars Lovee Sseneerarane Sty DOST Cempound. General Santos Ave. Bicutan, Taguig Cy Contact nos. (02) 838-0083, (02) 837-1385, 837-2071 loc. 2382 vwivw-s0 dost.gov ph