0 BE FILLED-OUT 8Y DOSTISEI STAFF ONLY ToC APPLN.NO- 2018 Tata Annual Famly Gross come: (Tarable & Nortarable) ‘ve. Bectity Consuretion ford months: arual HS Net Tato & Other School Fees Ounership of Vehicle Scholarship Program Assessment [-] RATo87 [meri p200.00/0.8 No Aasessed by Printed Name / Signature se [] 00st Ro. No, Republic of the Philippines kwh 2020 DOST-SEI APPLICATION FORM FORM A~ PERSONAL INFORMATION Instucton' inte leary in CAPITAL LETTERS your persona nvomaton the box powced or check te box forthe approprate answer. AvoIS erasures. For ‘any erasure, the applicant should countersign the dom corcted along te page margin, PLEASE ANSWER ALL ITEMS. SCIENCE AND TECHNOLOGY UNDERGRADUATE SCHOLARSHIPS Deadline or Fling of Application: September 6, 2019, Ittach ancther COPY Schedule of Examination October 20,2019 | tthe same 1x1" photo Department of Science and Technology EE SCIENCE EDUCATION INSTITUTE P.O. Box 18 Taguig Post Office Attach recent axa" photo here nce offialy stamped, 'DO NOT detzch photo Morte Test Pernt T. PERSONAL DATA, Name of Applicant ¢ast™iame AstName, Made Name, SuRXNane} DepEd Learner Reference Number Dated Bith passin: | Pace o Bia Naber of Chlcreninthe | Sih Order of Applicant cma cma ex i Family. Tee oie Phone Na Email arene Gizenstip Gale OFemale Permanent Adress Foe/Dio, Steet Tai, VingwBSreny: Doyen ave tar ee pea HOW No SRR Fone Bee Dr ave yu been wsveaa | Hyt,wie We Papa paper Dyes ONo Type at Soho ‘Serior High Shoal Srand Clregiarewiens Clscercens Clenaens Clueniycorgoaeaseerns | STEM — CNON-STEM Tame o School Tasiess ot Soha “Annual Taio and ther School Fees TL FAMILY DATA egal Guardian Father Mother ose preneare cee tang ‘paraansnp) Name Contact Number Highest Educational Atainment ‘ecupation ws. spec) Name of Employer Employer Address "2018 Annual Gross Income ir pesas one anno 220) Wf setlemployed, declare 2018 Annual Gross Income Tg your household nchided in the DSWD Listahanan 207 Lives CINe ery pease rae ear pho Dcopy a our OSHO ID) 1g your family a beneficiary ofthe DSWD's Pantawid Pamilyang Pilpino Program (#Po)? Yes (Gres ease rouse cearpoBcopy tour amy 4210) Ne Ti, SCHOLARSHIP INTENTIONS DATA (Check appropriate box for scholarahip program apple fr RA 7687 SCIENCE AND TECHNOLOGY SCHOLARSHIP For an applicant who belongs to 2 family whose socio-economic status does not exceed the set values of ALL the identified indicators a5 approved by the Advisory Commitee on S&T Scholarships DOST-SEI MERIT SCHOLARSHIP Ft an applicant who belongs to 2 family whose socio-economic status exceeds the set values of any of the identfed indicator ‘Applicant must pay a non-refundable test fee of P200.00.ER RNa I. HOUSEHOLD PROFILE, Profle of household members (Please inlae only the parents applicant and applicants siblings who are single, age 21 and below, ive under the same reat and share in common food) /(bilarg ang mga magulang, apilante at mga fapatd ng apliante na walang asawa, may edad 21 pababa, kasallayang akatra sa bahay at asama’sa nihahaing pagkain) Tame Relsionship|Age] vl] Highest | Grade arVear | Occupational | Gass at | Gross Feome (Putronsenourexd-asmstn ne steko |to Appleart | | Status | Edueational | “Attendingit’ |" Werking | Worker | forthe Year tame orp Gee | attainmert | Curertlyin | Household | Gee | 2018 mn pesos) aos | cpecrygrce, | Schoo! Member | ors et) | jorardeges) see) © a lel ° © ® ° ® B i g g F. g fe "ected he vray OWE We CAT sauce Ream Bre Ry. eo SS TSpONGD He nan are Ge ousevOEe be pron wo regres ih Bye members Pe house Tota | [cour orCovunn 4 i eo ‘Coase tr Coun eass armani SShge ows Srprse loweton E-Eapoyer cay tanyope rea om busness fi ares Scions bipmae estomimest FoWionr'nm payor owt Smirapeamee mice la Wcowe Wome brgoiennestagereyeoportot G-Wens wmentpayo ont omieopectea B= buonscicepames DoSereepoeaumettatyenpeye g.consan —” mbtinese = vow Sbre omer aecanaten) Ho Ghempoyed feg tous) TI, FINANCIAL CONTRIBUTION both parents are unemployed, co you have any sbing/s ar relatvele other tan tose named nthe (Z]oucehold Prafe (whether Fee or abroad) whi contibute in meeting yourfamiy and school expenses? Ives CIN Purpose of Financial Cortribaion ‘Relationship of Cortibitorto Applieart | Frequensyf Cocibution | Annual Contibulion (6g, eavstonal assis) (Ea, bere ican OF (ee coaes bau). ness) Coaes Tor Cotas FrequencyefConrbuteny A~woray S-Giamy _C-SmIAwal O-Amal Ev megiar | Total Total Annual Household Gross Income in 2018 (Z. Household Profile + IZ Financial Contribution) Basia Ang may sarting negotyo ofstang mg kumintang miyembro ng pam 1 Rangang tunang nang ge munis ts paisa find nanan (no {igang tant a pamiyeay aangang magoigay ng hopyang neoms Tax Retin TR} 0 Wi2 par noms) magoata nghopyeng SiR Cartan of Exemption ngs ng hopya ng BI Cartcaon of Eempton ng pag lng Ro Carkteaton of haigney ong 20 ng TIL, OTHER HOUSEHOLD INFORMATION Electr Consumption forthe fast Three Months Doe youTan Hae CCHS WS OBE ETE? wort wor worn Gres ONe he hh avn | yes.pae aconpin te Certs ot ce Stang CERTIFICATE OF ELECTRIC SHARING This i to certty that {amilies are shating inthe payment of electric bils under the name of. No arama) with address ‘They ate paying the folowing amount . Timoart Gapeses Sapstare ot] Cetitied True and Corec: Name of Family Head Wort | Worth? | Worth] Famly Heads 7 2 3 a pe = Fanted Wane & Signature of Saangay OWE tte SET ae ET ‘wnersiap othe housing unt Laan? ™ Laeaaane Townes, Fuly Paid Rented Clothers. ps. specity Townes, Amortized GlRentfeefiving wth relatives ‘Does your farily own agieutural andor non-esidertal and? Gives GN ye, igi be bara» rotor meee? sm Does your farily own vehicles? Lives CIN Tw To. of worling units [Year Model zea 2008) [Mia ex rend, Sumit Top08) Tiiyele Passenger vehicle (eg Jeapney, Van.) CavAUVISUV TruaiBiFORM C — CERTIFICATE OF GOOD MORAL CHARACTER ‘TOWHOMIT MAY CONCERN: This to cert that has consistenty maintained good moral character, ane OTA there having no ds plinary action taken against himher as ofthe date of application ‘Prnted Name & Signature of Puncpaludance Counselor Date NOTE: Fate » mamaw good mol oar neve Be 2vaN of he scoranp cal case rene Nero. DOSTSEI may que ano er crtcaton bebe De spay of Be ‘SauerpApenen shake apcan way een eae eas a ‘TOWHOMIT MAY CONCERN: This to certty that have examined, and found that helshe is FIT to study. EEO ARBATT ‘Wedleal Doctor School Physicians Printed Name & Signature License No, Date FORM E1 — PRINCIPAL'S CERTIFICATION (For Applicant from the STEM Strand) ‘TOWHOMIT MAY CONCERN: This to cert that is a candidate for the Grade 12 graduation under the Tae oa STEM Strand ofthe forthe SY 2019-2020, ae oS Printed Name & Signature of Principal Date ToC aie, ene eee ee ‘TOWHOMIT MAY CONCERN: This to cert that 's a candidate for the Grade 12 graduation under the Tae oa NON-STEM strand forthe SY 2010-2020 and f classified within the upper five percent of students in the graduating class. ool nuiberoTeRaRTTS woes) NOTE: Pease cers based on aplcant academic Sano as oF grat 11 [er bpbuanisncreee) Printed Name & Signature of Pineal Date FORM F — CERTIFICATE OF RESIDENCY (For RA 7687 Applicants only) ‘TOWHOMIT MAY CONCERN: This to cert that is a bonafde resident of TERE OTA fornot less than 4 years. FoneaT aR Printed Name & Signature of Barangay OMGalPrinepal Date This is to certify that my son/daughter immigration to the USA of any other county. ‘hae oa has no pending application for Printed Name & Signature of Parent Date