RIC Form No.

04
Series of 2021

2021 REGIONAL INVENTION CONTESTS AND EXHIBITS

For Region II

WAIVER

KNOWN ALL MEN BY THESE PRESENTS:

That I/WE, ALJAY R. YLAGAN, contestant/s in the SIBOL AWARD (Outstanding Student Creative
Research) with the entry entitled, “ELECTRICAL CONSUMPTION MONITORING SYSTEM WITH RFID
ACCESS CONTROL,” hereby state that I/we are aware of all the rules and regulations set forth in the
Contest.

By virtue hereof, I/we shall abide by the decision of the Board of Judges and hereby waive whatever
cause of action which I/we have or may hereafter have against the members of the Board of Judges, the
Department of Science and Technology Regional Office (DOST RO), the Technology Application and
Promotion Institute (DOST-TAPI), and their employees that may arise from or relative to the conduct,
results, etc. of the Contest.

IN WITNESS WHEREOF, I/we have hereunto set our hands on this __________________________ day
of _________________ 2021 at __________________________________________________________.

_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
Advisers/Guardians Contestant/s

* For Group work, all members must sign.

Signed in the presence of

_______________________________________ _______________________________________
Witness Witness
Address: Address:
__________________________________________ __________________________________________
__________________________________________ __________________________________________

SUBSCRIBED AND SWORN TO before me this _______ day of __________ 2021, at

_______________________, Philippines, affiant ___________, exhibiting his proof of identity
as above stated.

Doc. No.: ________

Page No.:________
Book No.:________
Series of 2021

Please submit or email this form together with the accomplished waiver form to DOST-TAPI not later than 5:00
PM on the Deadline of Submission of Entries.