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