august25,2017 ./:l:1- -...

Republic of the Philippines Department of Education National Capital Region

~.~~~~~~.~~~~~~-~~~~~~~~

DIVISION MEMORANDUM

No . ./:l:1- s. 2017

To: Assistant Schools Division Superintendent Chief Education Supervisor, SGOD Chief Education Supervisor, CID All Senior High School Principals/OICs

August25,2017

DepEd ·IVP_;~'T·''LUPA

RELEAsto_ . ~ DATE hr

SCIENCE EDUCATION INSTITUTE - SCIENCE & TECHNOLOGY SCHOLARSHIP PROGRAM FOR SHS STUDENTS

Attached is the letter from the Office of the Representative of the Lone District of Muntinlupa, Hon. Razzano Rufino B. Biazon, dated August 16, 2017 re: S&T Scholarship Programs of the Science Education Institute - De artment of Science & Technology (DOST), for the information and guidance of all co med.

Immediate and wide dissemination of this Memorandum is desi ed.

MAURO C. D ULAN, Ed. D. Schools Division Superintendent

17 August 2017

ROZZANO RUFINO B. BlAZON Representative

Lone District of Muntinlupa City

DR. MAURO C. DE GULAN, ED. D. Superintendent Department of Education Division Office Muntinlupa City

Dear Dr. De Gulan:

Forwarding to you the attached Application Forms for S& T Scholarship Programs of the Science Education Institute - Department of Science and Technology (DOST) for dissemination to graduating students in the Senior High Schools who are interested to pursue courses in the field of science and technology.

Thank you.

Very truly yours,

Republic of the Philippines

DEPARTMENT OF SCIENCE AND TECHNOLOGY

OFFICE OF THE SECRETARY

26 July 2017

HON. ROZZANO RUFINO B. BlAZON Representative Muntinlupa City, Lone District Rm. SW A-425, House of Representatives Quezon City

Dear Representative Biazon:

oFFICE OF CUNG. BlAZON RECEI V ED

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We are pleased to inform you that application for availment of the S&T Scholarship programs of the Science Education Institute, an attached agency of the DOST, is now open and details of which are shown below:

Program Deadline of Filing of Date of Examination Application

2018 Undergraduate Scholarships (RA 7687 and Merit)- for graduating senior August 25, 2017 October 15, 2017 high school students.

2017 Junior Level Science Scholarships - for third year college students enrolled in September 22, 2017 November 19, 2017 the priority S&T courses.

For wider student participation in these scholarship examinations, may we request the assistance of your office in the dissemination and distribution of the enclosed posters, information sheets and brochures to interested applicants and educational institutions.

Thank you for your usual support to the S&T Scholarship Programs.

Very truly yours,

~-r. ~.,e;;t:;f ~ FORTUNATO T. DELAPENA Secretary

Encl:a/s

&'Jt<!( ,,_ .,.,, ~'

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fD-- "!:]: .-.. . Postal Address: P.O. Box 3596 Manila Cable Address: Science Manila

Head Office: Bicutan, Taguig, Metro Manila Tel. Nos. 837-29-39 (DL) 837-20-71 to 82 (TL)

0. Where to Secure I File Application

• ~he app1icanon 'arm can De obtamea at the Sc1ence Eoucat1on nsnlute, 2nd Level. Sc1ence rlentage Bldg .. DOST CmDd .. General Santos Ave .. Bicutan. Tagwg City, Metre Mamla: DOST Reg1onal Offices; Prov1naal Sc1ence ana Tecnnology Centers (PSTC) or Offices of the Congressmen ana Senators. It can be oownloaded at the webSite, .WII.Y ~eLCOSi.QOV.iJn.

• Accomplished form can be filed at the Sc1ence Education nstilute, or DOST Reg1onal Office/PSTC nearest the applicant's school or home aadress.

Deadline for Filing of Application: September 22, 2017 Date of Examination:

November 19, 2017 (Sunday)

• The Test Perm1t shall be mailed to the applicant. In case the test permit is not rece1ved within the week before the examination day, the applicant may 1nqwre from the DOST Regional Office/PSTC and check the nearest des~nated test center a day before the examination.

E. Test Fee

• For Merit applicants, a non-refundable test fee of P200.00 w1ll be collected. They should send postal money order instead of cash when mailing applications. The payee of the money order should be SCIENCE EDUCATION INSTITUTE.

• SEI can aacept only cash, postal money orders, telegraphic transfer, certified cashier's and manager's checks. PERSONAL CHECKS ARE NOT ACCEPTABLE.

F. Selection Criteria

The awardees shall be selected on the basis of their performance in the 2017 Junior Level Science Scholarship Examination.

G. Final Selection

The list of awardees as approved and announced by the DOST Seaetary is final and unappealable.

~ J.GI_cf-l.losETTE T. BIYO

Director

Department of Science and T echoology SCIENCE EDUCATION INSTITUTE

1st and 2nd Levels, Science Heritage Bldg., DOST Compound, General Santos Ave., Bicutan, Taguig City

Contact nos. (02) 839-0083, (02) 837·1333, 837·2071 klc. 2382 www.sei.dost.gov.ph

I.

.Types of _Scholarships

~ETU~N OF SE~VICE CONOITION

Upon completion of the S&T course, the scholargraduate shall teach full time high school subject/s, namely:

• Agricultural • Aquaculture • Biology • Chemistry • Fisheries Technology • Information Technology • Mathematics • Physics

in any high school, public or private of his/her choice within the country, with first priority in his/ her home province for a minimum period of two

years.

• State Universities and Colleges (SUC) • CHED identified Centers of Excellence (COE)

or Centers of Development (COD) for the priority S& T courses

• Institutions with FAAP Level ill Accreditation

Upon completion of the S& T course, the scholar- t ...:..e,_;_" --~ graduate shall render service in the country preferably along his/her field of specialization on a full-time basis for a minimum period equivalent to the length of time he/she enjoyed the scholarship.

Aeronautical Engineering

Aerospace Engineering

Agribusiness Management

Agriculture

Agricultural Biotechnology'

Agricultural Chemistry

Agricultural Economics

Agricultural Engineering

Agricultural Technology

Agricultural and Biosystems Engineering

Applied Mathematics

Applied Physics

Applied Statistics

Animal Scienoe

Biochemistry

Biology

Ceramics Engineering

Cliemistry with Applied Computer Systems

Chemistry with Materials Science and Engineering

Chemical Engineering

Chemistry

Civil Engineering'

Computer Engineering

Computer Science

Electrical Engineering

Environmental Scienoe

Fisheries

Food Technology

Forestry

Geology

Geodetic Engineering

Geothermal~n~i~enng

Industrial Design

Industrial Engineering

Industrial Management EngineeringInformation Technology2

Industrial Pharmacy

Information System

Information Technology

Information Technology Systems

Instrumentation and Control Engineering

Manufacturing EngineeringManagement-Biomedical Engineering2

Manufacturing Eng'g.-ManagementMechatronics and Robotics2

Manufacturing Engineering

Materials Engineering

Mathematics

Nutrition and Dietetics_

Pharmacy (4-year program)

Packaging Engineering --~ -- ---~-~

Physics ~

Psychologf

Public Health

Scienoe Teaching (Biology, Chemistry, Physics and Physical Scien~ )4 _

Statistics

Mathematics Teaching• Doctor of Veterinary Medicine

Mathematics and Science Teaching• Note: 1at UP System only

Marine Biology 2at DLSU only 3BS Program

Marine Science •For RA 7687 and MERIT only

TO BE FILLED-OUT BY DOST/SEI STAFF ONLY TCC APTLN. NO.

I I 1-1 1 I I 2016 Total Annual Femily Gross Income: ul P:._ ____ _J

(Taxable S Non -taxable) Month 1 kwh Average Electricity

Consumption in kwh:

Annual HS Net

Month 2 Month 3 Total= CV=

kwh kwh

I 3 mos. kwh

TuitionS Other School Fees: ul P:._ ____ _J

Scholarship Program Assessment: D RA 7687 D Merit P 200.00/0.R. No. _ ___ _

Assessed by:

Printed Name/Signature D SEI 0 DOST RO. No.: _

Republic of the Philippines Department of Science and Technology

SCIENCE EDUCATION INSTITUTE P.O. Box 18 Taguig Post Office

APPLICATION FORM

for the

DOST-SEI SCIENCE AND TECHNOLOGY SCHOLARSHIPS FOR 2018

NOT FOR SALE CAN BE REPRODUCED

ALL ENTRIES/SIGNATURE IN THIS FORM MUST BE

ORIGINAL.

Attach recent 1" X 1"

picture here

Once officially stamped, DO NOT detach photo.

Attach another copy of the same 1" x 1"

picture for the Test Permit.

FORM A Instruction: The applicant must be the one to accomplish Form A and affix his/her signature together with one of his/her parents or legal guardian. Write clearly in the box provided or check the box for the appropriate answer. Avoid erasures. For any erasure, the applicant should countersign the item corrected along the page margin. PLEASE ANSWER ALL ITEMS.

Deadline for Submission: 25 August 2017 (Friday) Date of Examination: 15 October 2017 (Sunday) I. PERSONAL DATA

1. Name of Applicant Surname First Name Middle Name

3. Date of Birth 2. Sex D Male D Female L__ _____ __J 4. Place of Birth

L--------;::.._-~6'.:_. _::D~oJy~o~u~have a dual citizenship? Oves D No If yes,- please ~sp~e=c~ify'!_:::_:=====~ 7. Con~ctNos.: Landl~in~e~P~h~o~ne~N~o~. ~~~~~~~~~C~e:II ~P~ho~n:e~N:o~.~~~~~~~~~~~~8~.~E~m~a~i~IA:d~d~r~ess~:~~~~~~~~~~ 5. Citizenship

9. Permanent Address~~-~-~-----~---------~~~~~~-------=-~-----=~~~ No. Street Barangay City/Municipality Province

10. Number of Children in the Family D 11. Birth Order of Applicant (1st child, 2nd child, etc.) D

12. Senior High School Strand D STEM DNoN-STEM (Tobepro,.,.edb~~~ ~~--~~----------~~~~~~~~=±=±~~~~

13. Name of School

14. Type of School

15. Address of High School

D Regular Public High School D Science

High School D Private High School

16. Tuition and Other School Fees Paid in a Private High School I P "Please attach iJssessment fonn or statement of account provided by the L. ----------'

school If under scholarship: indiciJte 11iJme of scholarship~ i1motmt of grant and submit certification from school or foundation.

II. FAMILY DATA - - -

Father

18. Name --J9 . Highes~ Educational Attainment

l_q. Occupation (pis. specify) 21. Name of Employer

22. Em_Eioyer Address

23 . 2016 Annual Gross Income (in pesos; taxable and non-taxable)

24.Jf self-employed, declare 2016 Annual Gross Income ----

25. Tribal Affiliation If applicable, please submit a certification of membership from the local Office of Muslim Affairs or National Commission on Indiqenous People.

D University/Ccllege-based Senior High School

17. Have you been issued a passport? DYes DNa

.--==----==--~ If yes, please write the Passport No. t__ ______ _J

legal Guardian Mother (To be accomplished ONLY by those whose

parents are deceased, working abroad, etc; should submit affidavit of guardlanshlpi

- 26. Is your family a beneficiary of the DSWD's Pantawid Pamilyang Pilipino Program (4Ps)? o ves o No If yes please orovide clear ohotocooY of your family's 4Ps ID. ----

III. SCHOLARSHIP INTENTidNS DATA

27. Check appropriate box for scholarship program applied for:

D RA 7687 SCIENCE AND TECHNOLOGY SCHOLARSHIP For applicant who belongs to a family whose socio-economic status does not exceed the set values of ALL the identified indicators as approved by the Advisory Committee on S& T Scholarships.

D DOST-SEI MERIT SCHOL:ARSHIP For an applicant who belongs to a family whose socio-economic status exceeds the set values of any of the identified indicators. Aoolicant must oav a non-refundable test fee of P200.00.

28. Have you applied for scholarship other than the DOST -SEI? Oves 0No

If yes, please identify which scholarship: DOWWA OcHED OGsis [J Others, specify ____ _

.--------------------------------------------------, 29. College/University where you intend to enroll :

Note: You are advised to take the admission test of the college/university where you intend to enroll in SY 2018-2019.

30. Test Center nearest your school : Note: Please refer to the list of designated test centers in the 2018 S& T Scholarship announcement bro'thure. The scholarship examination will be administered on 15 October 2017 (Sunday) at an identified test center in your province.

I hereby certify that all answers given above are true and correct to the best of my knowledge.

Attested by:

Parent/Legal Guardian (Please print name and sign above it.)

FORM B- HOUSEHOLD INFORMATION QUESTIONNAIRE (HIQ)

A. HOUSEHOLD PROFILE

Signature of Applicant Date:

1. Profile of household members (Please include only the parents, applicant and applicant's siblings who are single, age 21 and below, live under the same roof and share in common food.) {lbilang ang mga magulang, aplikante at mga kapatid ng apllkante na walang asawa, may edad 21 pababa, kasalukuyang nakatira sa bahay at kasama sa inihahain paqkain.)

Name Relationship Age Civil Highest Grade or Occupation of Class of Gross Income for

(Put Household to Applicant Status Educational Year Working Worker the Year 2016

Head* as first in the (See Attainment Attending if Household (See codes (in pesos)

codes (Specify grade, Currently In Member below) list; include name of below) year or degree) School

applicant)

(1) (2) (3) (4) (5) (6) (7) (8) (9)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

*Household head usually provides the chief source of income for the family. He or she is responsible for the organization and care of the household or the person who is regarded as such by the members of the household.

Codes for Col. 4 (civil status):

1 Single 2 Married

Codes for Col. 8 (class of worker):

1 Works for private household 2 Works for private establishment

3 Widowed

3 Works for government agency/corporation 4 Self-employed without any employee

(e.g., sari-sari store o~ner, dressmaker)

2.a Annual Household Gross Income 2016 P

4 Divorced/Separated 5 Unknown

5 Employer in own family-operated farm/business 6 Works with pay on own family-operated farm/business 7 Works without pay on own family-operated farm/business 8 Unemployed (e.g . housewife)

~-----------~

.

2.b If both parents are unemployed, do you have any reltve(s other than those in the profile of household members (whether here or abroad) who contribute in meeting your family expenses? Yes D No If yes, please accomplish the table below:

Nature of Financial Contribution Relationship of Contributor to Applicant Frequency of Contribution Average Contribution

Paalala:

(e. g., remittances) (e.g., brother who is an OFW} (otease mark with YJ -(In pesos) ( ) Monthly ( ) Quarterly ( ) Every __ {no. of mos.)month

Kung ang mga magulang ay may hanapbuhay (employed) o di kaya ay may sariling negosyo, magbigay ng kopya ng Income Tax Return (ITR) o W-2 para sa taong 2016. Kung walang hanapbuhay (unemployed) ang ama, magblgay ng kopya ng BIR Certification o Municipai/Barangay Certification of Indigency o Exemption ng pag file ng ITR. Kung ang ina ay "housewife", hindi na kailangang magsumite ng nasablng sertipikasyon.

TEST CENTERS DOST REGIONAL OFFICES

CAR Abra, Apayao. Benguet, DOST--CAR lfugao, Kalinga, Mt. ?rov. BSU Campus. La Trimdad. Benguet

Tel. No. (74) 422-0979 Fax. No. (74) 422-2214

Reg1on I llocos Norte, !locos Sur, DOSTR.0.1 La Union, Pangasinan DMMMSU-MLU Campus

San Femando City, La Umon Telefax No. (72) 888-3399. 700-2372

Region II Batanes, Cagayan. lsabela, DOST R.O. 2 Nueva VIZcaya, Quirino Regional Govemment Center

Carig Sur, Tuguegarao, Cagayan let No. (78) 304-3426 Fax No. (78) 846-7241, 604-8654

Region Ill Aurora, Bataan, Bulacan. DOSTR.0.3 Nueva Ecija, Pampanga, Diosdado Macapagal, Gov'.'t Canter Tarlac, Zambales Maimpis. City of San Femando,

Pampanga Tel. No. (45) 455-2348 Fax No. (45) 455-0800

Region IV-A Batangas, C<Mte, laguna, DOSTR.0.4-A Quezon, R~al Jambore&Rd., Brgy. Timugan,

Los Bal'los, Laguna Telefax: (49) 53&4894

Region IV-8 Marinduque, Occidenial DOSTR.O. 4-B Mindoro, Oriental Mindoro, DOST Compound, Gen. Santos Palawan, Romblon Avenue, Bicutan, Taguig City

Tel. No. (02) 837-2071 1oc. 2093

Region V Albay, Camarines Norte, DOSTR.O.S CamarinesSur, Regional Center Site Catanduanes, Rawls, Legaspi City Masbate, Sornogon Telefax No. (52) 482-0534

Region VI Aldan, Antique, Ca~. DOSTR.0. 6 Guimaras, Iloilo, Magsaysay Village, La Paz Negros Occidental llo~oCity

Tel No. (33) 32(}0093 Fax No. (33) 320-0908, 508-7183

Region VII Bol'd, Cebu, Siquijor, DOSTR.O. 7 Negros Oliental The lahug S&T Complex

Sudlon, Cebu City Telefax No. (32) 418-9055

Region VIII Biliran, Eastem Samar, DOSTR.0.8 Leyte, Northern Samar, Government Center, Candahug Southem Leyte, P~o. Leyte Westem Samar Tel. No. (53) 323-5252.323-7111

Fax No. (53) 323-7110

Region IX lsabela City (Basilan), DOSTR.0.9 lamboanga del Norte, Pettit Barraclcs, lamboanga City Zamboanga del Sur, Tel No. (62) 991-1024 lamboanga Sibugay Fax No. (62) 992-1114

Region X Bukidnon, Carniguin, DOSTR.0. 10 Misamls Occidental, J.R. Borja Memorial, Compound. Misamis Oliental, Carmen, Cagayan de Oro City Lanao del Norte Tel No. (88) 858-6790

Fax No. (88) 858-3931

CARAGA Agusan del Norte, DOST--CARAGA Agusan del Sur, Dinagat CSU Campus, Ampayon, Butuan City Islands, Sllrigao del Norte, Tel No. (85) 341-9551 Surigaodel Sur Fax No. (85) 342-5684

TEST CENTERS DOST REGIONAL OFFICES

Regton XI Davao del Norte, DOST R.0.11 Davao del Sur. Oavao Meaical Center Comp .. Cor. Oavao Occidental. Friendship and Oumanias Rds. Davao Onental. Bajada. Davao City Comoostela Valley Tel No. (82) 221-5428

Fax No. (82) 221-5295

Region XII Cotabato City, North Cotabato, DOST R.O. 12 South Cotabato. Sultan L TP Compound. Cotabato City Kudara\ Saranga~ Tel No. (84) 421-6908

Fax No. (64) 221-5295

ARMM Basilan Province, DOST-ARMM Lanao del Sur, Maguindanao, ORG Com~ex, Cotabato Cily Sulu. Tawt-Tawi Tel No. (64) 391).1454. (64) 552-0263

Fax No. (64) 421-1975, (64) 421-8183

NCR Metro Manila

D. Examination Coverage

This scholarship examination is designed to measure abilities that detennine academic and professional success in science, technology, engineering, and mathematics. The test includes the following domains: Logical Reasoning, English, Science. Mathematics, Mechanical-Technical and a Self-Inventory part.

E. Seledion Criteria

The awardees shall be selected on the basis of their perfonmanoe in the 2018 S&T Scholarship Examination.

F. Final Selection

The list of awardees as approved and announced by the DOST Secretary is final and unappealable.

G. Terms and Conditions

a) An awardee must seek admission and enroll at any of the following: a.1 State universities and colleges. a.2 Tertiary institutions identified as Centers of Excellence or Centers of

Development by CHED or Level Ill accredited by FAAP for the priority S&T courses.

a.3 DOST-SEI identified networl< institutions.

HeiSho should pass tho qualifying oxamlnaUon for admission to the university whore holsho plans to enroll ln.

b) An awardee shall comply with the tenms of the Scholarship Agreement to be entered into between himself/herself, parents or legal guardian and the DOSTSEI.

c) After signing the Scholarship Agreement. the awardee's name shall be included in the lists of scholars needing clearance from DOST -SEI forwarded to the appropriate government agencynes for tracking purposes.

d) An awardee shall maintain the grade requirements of the scholarship. e) In case of a scholarship qualifier who comes from the non-STEM strand class, he/

she may avail of the scholarship as long as helshe is admitled in any of the priority S&T course in an accrndited university. In the event that the non-STEM strand scholarship qualifier is required to take back core-Science/Mathematics subjecUs in the STEM strand, helshe shall be advised to defer the DOST-SEI scholarship while being enrolled in said subjectls; new defenment policy shall apply.

RA 7687 Republic Act No. 7687. also known as the "Science and Technology Scholarship Act of 1994', provides for scholarships to talented and deserving students whose families' socio-economic status do not exceed the set cut-off values of certain indicators. Qualifiers must pursue priority fields of study in the basic sciences, engineering, olher applied sciences, and science and mathematics teaching.

MERIT The DOST-SEI Merit Scholarship Program, formerly known as the NSDB or NSTA Scholarship under RA No. 2067, is awarded to students with high aptitude in science and mathematics and are willing to pursue careers in the fields of science and technology.

Securing I Filing Application

o The application fonm can be obtained at the Science Education Institute, 2nd Level, Science Heritage Bldg., DOST Cmpd., General Santos Ave., Bicutan, Taguig City, Metro Manila; DOST Regional Offices; Provincial Science and Technology Centers (PSTC) or Offices of the Congressmen and Senators. It can be downloaded at www.sei.dost.qov.ph.

o Accomplished fonm can be filed at the Science Education Institute, or DOST Regional OfficeiPSTC nearest the applicant's school or home address.

# Deadline for Filing of Application:

August 25, 2017 Date of Examination:

October 15, 2017

o The Tesl Penmit shall be mailed to the applicanUs or school principal for distribution to the applicants. In case the test permit is not received within the week before the examination day, the applicant may inquire from the DOST Regional Office I PSTC and check the nearest designated test center a day before the examination.

~ j.$&.f-~OSETTE T. BIYO

Director

' Department of Science and Technology SCIENCE EDUCATION INSTITUTE

1st and 2nd Levels, Science Heritage Bldg., DOST Compound, General Santos Ave., Bicutan, Taguig City Contact nos. (02) 839-0083, (02) 837-1333, 837-207lloc. 2382

www.sei.dost.gov.ph

('

~.~-

HOLAR ATION!

S& T PRIORITY COURSES Aerol)3utical Engineering Chemical Engineering lnfonnation Technology

Molecular Biology and Biotechnology

Aerospace Engineering Chemistry lnlonnation Technology Systems Nutrition

Agribusiness Management Civil Engineering' Instrumentation and Control

Nutrition and Dietetics Engineering

Manufacturing Engineering-Agricullure Computer Engineering Management-B.iomedical Phannacy (4-year program)

Engineering'

Manufacturing Engineering-Phannacy major in Clinical

Agricultural Biotechnology ' Computer Science Management-Mechatronics and Phannacy (5-year program) Robotics'

Agricullural Chemistry Electrical Engineering Manufacturing Engineering Packaging Engineering

Agricullural Eoonomics El!lC!ronics and Communications Materials Engineering Physics

Engineering/Electronics Engineering

Agricullural Engileering EnVironmental Science Mathematics Applied Physics with Applied

Computer System

Agricultural Technology Fisheries Mathematics Teaching Applied Physics with Materials

Science and Engineering - --

Agricullural and Biosystems Food Technology Mathematics and Science Teaching Petroleum Engineering Engineering

··~ .... · Applied Mathematics Forestry Marine Biology Psychology'

.-, -.-.~ -- ·' ~

Applied Physics Geology Marine Science Public Health

Science Teaching (Biology, Applied Statistics Geodetic Engineering Mechanical Engineering Chemistry, Physics and Physical

Science)

Animal Science Geothennal Engineering Mechatronics Engineering Statistics

Biochemistry Industrial Design Medical Technology Doctor of Veterinary Medicine --·-'!.."!"""

l~dustri81 Eilgi~g _ -

Biology Metallurgical Engineering

Ceramics Engineering Industrial Management Engineering-

Meteorology 1at UP System only lnlonnation Technology'

Chemistry with AWtled Computer Industrial Pharmacy· Microbiology 'at DLSU only _,~s~

"' ~··· •4;1(' :,. •. _ _..•, -Chemistry with Materials Science lnfonnation System

and Engineering

• State Universities and Colleges (SUC)

• CRED identified 'centerS'" of Exceiience-(COEfor~Centers .of Development lCOD) forthe priority S&fcourses: _ - -

:;.: ·.1 ...., ,..: ~"~, .........

• Institutions with FAAP Level ill Accreditation

.._

Mining Engineering ass Program

Upon completion of the S&T course, the scholar-graduate shall render serviCe in the :t;oun!rrpreferably ~long hiS/her' fielcfOf specializatioh on a tuli'lime basiS-tOr a minimum period equivalent to the]ength of time he/she-enjoye&the scholarship. = ~

• natural-bam Filipino citizen;

• poor. talented and deserv1ng student who belongs to a fam1ly whose socio-economic status does not exceed the set values of certa1n indicators;

• member of the top five percent (5%) of the Non-5TEM strand senior high school graduating dass; or

• member of the STEM strand senior high school graduating class;

• resident of the municipality for the last 4 years as attested by the barangay chairman;

• of good moral character and in good health; and

• qualifier of the 2018 S& T Scholarship Examination

Tuition and other school fees

Book Alklwance MSIPE uniform (1st Semester of First Year only) Group Insurance Transportation Allowance (for those stJJdying outside of home province)

Monthly Living Allowance • ForBS Physics I Applied Physics I Physics Teaching /Geology I Mining Eng'g/

Agriculture I Fisheries

-"'alioli ., -., -.,

~ ., . .,

. . -::--- -- --_,-----

-P1o.ooo.OOJsemester

or P8,000.0011rlmester P1o;OOQ.OO/yeiiir - . P1,000.00

Ptemiurrr

1 economy-<:lass ~fan! ' ~

-

,_

:illJ ., " .,

" ., ,{"

P10,000.00/semester or PS,OOO.OO/trimester

P10,000.00/year P1,000.00 Premium

t economy-dass roundtrip fiinr

• Other DOST -SEI priority oourses ~:~. ;~;;;: -:~:::::· '~ ""' ;_ - 1>3",200.00/mo.~

Summer Allowance (if required per cuniculum) • Tuition and other school fees I - .,c~ _ c~j;;!Xlr · -~,joo_oo • Book Allowance . '~:( ~~@~:®J'I , _ _ PSOO.OO (to5ubni(QR.)

• Morlthly Allowance ~;T;C~: ;~~$~~~r_ ~"""~- ;..,::: ;.; · '"~§f-~z.roontbs-. __ ..,., • ,..,._.,.,.~-~,--....,.,...._.1 r pf """'()() ,.,. ........ ...._.,...-..

_ ·- _ ..,.., , - --:;: :;..r • ..,;;.p_Vt,uuu.;uu.. - - ,yvv. II.WR: o)W,IIJfGl~ '-""11

~ -~;~:--:.=~~?~-.}i· . Post -9raduation clothing allowance

• Fonn A: Personal lnfonnation ?:.:::~~ .. :~ -~~~:-:-.~~:~ · - " • Form B: Household lnfonnation Questionnaire b:~~- :.:;; .. ~~~~.::-:-~ ~

., -::=-

• Fonn C: Certificate of Good Moral Character 1§:<.~·.:-"0-~:t't~~f:_'f~~ ~ _.;.-"".::!.-'-"

-r • Fonn 0-1 : Certification that applicant belongs to the senior high school STEM strand class .. ~=:- -~-~:~~-~~:~_-1::i

~ ~-- _..~-.;.·.:..-

• Form 0-2: Certification that applicant belongs to the upper 5% of the NON-5TEM strand senior high school graduating class ~~ ~ -:; . .-;~~y;;~I~~~~fl-- .r i~'!-f::_ .- ,.,

• Fonn E: Statement of applicant that he/she has not taken any previous DOST -5EI Undergraduate Scholarship Examination and any undergraduate units or ~ '' _, post secondary course · ·

• Form F: Statement of parent that applicant has no pending application as immigrant to any other country

• Fonn G: Certificate of Residency -~';; ·"":-= · ~ -:_~~~_.,; :;~ ~ -

•Tworecent (1"x1i pictures ~->· ,~-i::-f~::;..:;-=:;::;:- -~ ~- "'·· r _ -~ •PholooopyofBirthCertificate <.:-_;;;;*·~-: C:.r:'i;~~~~-~- ;:- "":. ---~ • Parentis 2016 lnoome Tax Return I W21 Empklyment Contract for OFW I SIR Cert of : ~ f . "'--:;' $->;."'; ;:-_:j._ "' .~ . • '~ ~ • ~"':~. ·

Exemption from Filing of ITR I Brgy. Cert. of lndigency :--,;.-~- ' >- .;:ia.~·'-'""- . - ·• •EiectricbiUfor3oonsecutivemonths in2017 ':0""j~r-....r~..:,;,:,""':; _ ~ .~·- ~ ~

•Non-iefundabletest feeofP200.00 '!>; , , :~--£"- .:;,~; • They should send postal money oroerinstead of cash when mailing applications. , . _.,-:~,._.-~- : ' ~

The payee of the money oroer should be SCIENCE EDUCATION INSTITUTE. "'). : :;• · :~:_.~ • SEI can only accept cash, postal money oroers. telegraphic transfer. certified :c . .::_ :} • . _:-,·_-·J:f' _ ~.

cashier's and manager's checks. PERSONAL CHECKS ARE NOT ':B":"'i ~i:- >:..; .. ;c:, ;•~ ;'~": >I,. ACCEPTABLE. '; 'r:::;r:,_::;'i!;:' :! ~ - : , :.:-.._

., ~·~

.:4.f:.._

TO BE FILLED-OUT BY DOSTISEI STAFF ONLY

TCC APPLN. NO.

I I I - I I I I 2016 Total Annual Family Gross Income: (Taxable & Non-taxable) P ______ _

Average Electricity for 3 months: _ ___ kwh

General Weighted Average:

Scholarship Program Assessment:

§ RA 106 12

RA 7687

MERIT P200.0010.R. No. ____ _

Assessed by:

Printed Name I Signature

D SEI 0 DOST RO. No.

FORM A - Personal Information



2017 JUNIOR LEVEL SCIENCE SCHOLARSHIPS

APPLICATION FORM

Deadline for Filing of Application: September 22, 2017

Schedule of Examination November 19, 2017

STS0-1011 Rev. 0/11-09-15


ALL ENTRIES/SIGNATURE IN THIS FORM MUST BE ORIGINAL.

Attach recent

1" X 1"

photo here

Once officially stamped, DO NOT detach photo. Attach another copy

of the same 1" x 1" photo for the Test Permit.

Instruction: Write clearly in the box provided or check the box for the appropriate answer. Avoid erasures . For any erasure, the applicant should countersign the item corrected along the page margin . PLEASE ANSWER ALL ITEMS.

I. SCHOLARSHIP INTENTIONS DATA Check appropriate box for scholarship program applied for: Forms to be filled-out

RA 10612 For an applicant enrolled in science, technology, engineering and mathematics who shall teach Form A, C, D and F2 science, mathematics and technology in any of the secondary schools throughout the country.

RA 7687 For an applicant who belongs to a family whose socio-economic status does not exceed the set Form A, B, C, D, E and Fl values of ALL the identified indicators as approved by the Advisory Committee on S& T Scholarships.

MERIT For an applicant who belongs to a family whose socio-economic status exceeds the set values Form A, C, D and Fl of any of the identified indicators . Applicant must pay a non-refundable test fee of ~00.00.

II. PERSONAL DATA ,_----------~--------------------------------------------------------------, 2. Name of Applicant

Surname First Name Middle Name

3. Sex D Male D Female 4. Date of Birth 5. Place of Birth

6. Citizenship 7. Do you have a dual citizenship? D Yes

8. Contact Nos.: Landline Phone No. Cell Phone No . ..-------- 9. Email Address:

10. Permanent Address

No. Street Barangay City/Municipality Province Zip Code

11. Number of Children in the Family 0 12. Birth Order of Applicant (1st child, ZW child, etc.) 0 13. Course Enrolled in

14. College I University Name

15. College I University Address

16. Have you been issued a pas sport? DYes D No If yes, passport no. l III FAMILY DATA

Legal Guardian

Mother (To be accomplished ONLY by those

Father whose parents are deceased, working abroad, etc; should submit affidavit of

guardianship)

17. Name

18. Highest Educational Attainment

19. Occupation (pis. specify)

20. Name of Employer

21. Employer Address

22. 2016 Annual Gross Income (in pesos) (taxable and non-taxable)

23. If self-employed, declare 2016 Annual Gross Income.

24. Tribal Affiliation* If applicable, please attach a certification of membership from the focal Office of Muslim Affairs or National Commission on Indigenous Peoples.


Attested by:


Signature of Applicant

Date:-------------

FORM B- Family Socio-Economic Information {For RA 7687 Scholarship Applicants Only) Paalala:

• Kung ang mga magulang ay may hanapbuhay (employed) o di kaya ay may sariling negosyo, magbigay ng kopya ng Income Tax Return (ITR) o W-2 para sa taong 2016.

• Kung walang hanapbuhay (unemployed) ang ama, magbigay ng kopya ng BIR Certification o Municipai/Barangay Certification of lndigency o Exemption ng pag file ng ITR.

• Kung angina ay "housewife", hindi na kailangang magsumite ng nasabing sertipikasyon.

25. If both parents are unemployed, do you have any relatives , (whether here or abroad) , who contribute in meeting your family expenses?

DYes 0 No If yes please accomplish the table below·

' Nature of Financial Contribution Relationship of Contributor to Applicant Frequency of Contribution Average Contribution

(e.g., remittances) (e.g. , brother who is an OFW) (see codes below) (In pesos)

Codes for Col. 3 (Frequency of Contribution): A-Monthly B-Quarterly C-Semi Annual D-Annual E-lrregular

.--------------------, 26. Total Annual Family Gross Income 2016

L_____-----;::::============--, 27. Electric Consumption for the last Three Months kwh kwh kwh

(Note: Provide clear photocopies of the electrical 2017 2017 2017 bills. Present original copies for verification.)

28. Are you a beneficiary of the DSWD's Students Grants-In-Aid Program for Poverty Alleviation? 0 Yes 0 No

29. Ownership of the housing unit: (Indicate answer in the box provided) D 1-0wned, Fully Paid 2-0wned, Amortized 3-Rented 4-Rent free/living w/ relatives 5-0thers, pis. specify _________ _

If rented, how much is the monthly rental? I pp /month I If amortized, how much is the monthly amortization? . /month .

30. Owns agricultural or non-residential land? (area in sq. m) 0 None 31 . Indicate name(s) of existing credit card of the family members, if any: 32 Does your family own any of the following appliances facilities and vehicles?

' No. of Working Units ApplianceNehicle Mode of Acquisition Brand/Model Year Acquired

Aircondition

Video Camera or Movie Camera

CarNan/Pajero/Other Similar Vehicle - Jeepney (AUV/Owner Type)

lpod/lpad

Laptop/Desktop

Industrial Freezer

. Industrial Dryer -

Electric Water Pump

FORM B (Continuation) CONTACT ADDRESS/NO. (Indicates as many as possible) Mailing Address

Appplicant Parent/Legal Guardian Landline Phone No.

Cell Phone No.

Fax No.

Email Address

1---------lll~---------1

SIGNED DECLARATION BY THE PARENTS/LEGAL GUARDIAN: 1/We hereby certify to the truthfulness and completeness of information provided. Any misinformation or withholding of information will

automatically disqualify my/our son/daughter from the DOST-SEI Junior Level Science Scholarship Program. 1/we are also willing to refund all the financial benefits received plus the appropriate interest if such misinformation is discovered after my/our child accepted the award.

In connection with this application for scholarship, 1/we hereby authorize the DOST-SEI designated representative to conduct a credit check on the family finances, including bank accounts, credit card accounts, SSS and GSIS accounts, and to visit our family dwelling.

Father's Signature Over Printed name

or Legal Guardian's Signature Over Printed name

FORMC

TO WHOM IT MAY CONCERN:

Mother's Signature Over Printed name

Date

CERTIFICATE OF COURSE AND YEAR LEVEL

This is to certify that----------....,..,..----,-,---:-:--,---------- is presently enrolled in Bachelor of Science in Name of Applicant

---------::-:-c-:---:--::--....,------------ as a REGULAR THIRD YEAR student for First Semester SY 2017-2018 at the Field of Study

College/University

Printed Name & Signature of College Dean

Date: __________________ __

FORM D

CERTIFICATE OF GOOD MORAL CHARACTER


This is to certify that -----------:-:--:;-:---::--:----------·has consistently maintained good moral character, Name of Applicant

there having no disciplinary action taken against him/her as of the date of application.

Printed arne & Signature of Dean of Student Affairs

Date. _ _________________ __

NOTE: Failure to maintain good moral character before the award of the scholarship shall cause forfeiture thereof. DOST-SEI may require another certification before the signing of the Scholarship Agreement sho · ·

FORM E (For RA 7687 Scholarship Applicants Only)

CERTIFICATE OF RESIDENCY


This is to certify that _____________ is a bonafide resident of -------:-:-----:-::--:--c:---:-=-------Name of Applicant Name/Address of Barangay

for not less tha 4 years.

Printed Name & Signature of Barangay Official

Date:------------------

FORM Fl (For RA 7687 and MERIT Scholarship Applicants Only)

COMMITMENT TO RETURN OF SERVICE

This is to certify that the undersigned AGREES to render service in the country preferably along his/her field of specialization, on a full-time basis for a minimum period equivalent to the length of time he/she enjoyed the scholarship.

Noted by:

Printed Name & Signature of Parent Printed Name & Signature of Applicant Date: ________________ _ Date: _________________ _

FORM F2 (For RA 10612 Scholarship Applicants Only)

COMMITMENT TO RETURN OF SERVICE

This is to certify that the undersigned AGREES to teach in the secondary level of basic education in a public or private high school in the Philippines as return of service (ROS). In case of failure to comply with the terms of the Service Agreement, the undersigned agrees to repay the amounts disbursed, plus applicable interest.

Noted by:

Printed Name & Signature of Parent Printed Name & Signature of Applicant

Date:----------------- Date: _________________ _

For DOST SEI/RO staff use only : List of Lacking Requirements

Form A- Personal Information Form B - Family Socio-Economic Information (for RA 7687 only) Form C- Certificate of Course and Year Level Form D - Certificate of Good Moral Character Form E - Certificate of Residency (for RA 7687 only) Form F1 - Commitment to Return of Service (for RA 7687 and MERIT) Form F2- Commitment to Return of Service (for RA 10612 only) Official Transcript of Records (TOR) or Certified True Copy of Grades (TCG)

Two recent (1" x 1'1 pictures Photocopy of Birth Certificate Parentis 2016 Income Tax Return I W2 I Employment Contract for OFW I BIR

Certificate of Exemption for Filing of ITR I Municipal or Barangay Certificate of lndigency (for RA 7687 only)

~ Electric Bill for 3 consecutive months in 2017 (for RA 7687 only) If legal guardian, affidavit of guardianship If applicant has tribal affiliation, Certification of OMNNCIP

Others:------------------------

THIS APPLICATION FORM AND ATIACHED DOCUMENTS WERE

VERIFIED FOR COMPLETENESS BY:

Printed Name/Signature

Date of Review of Documents: _______ _

Date of Return of Applicant: _______ _

Remarks:

TO BE Fll,LED-OUT BY DOST/SEI STAFF ONLY TCC APTLN. NO.

I I ·1-1 1 I I 2016 Tatal Annual Family Gross Income: L!.l P ____ -.J

(Taxable a Non-taxable) Month I ___ kwh Average Electricity Month 2 kwh

Consumption in kwh: Month 3 kwh Total= ___ I 3 mos. CV= kwh

Annual HS Net Tuition li Other School Fees: L.!l P _____ ...J

Scholarship Program Assessment: D RA7687 D Merit P 200.00/0.R. No. ____ _

Assessed by:


D SEI D DOST RO. No.:_



APPLICATION FORM

for the

DOST-SEI SCIENCE AND TECHNOLOGY SCHOLARSHIPS FOR 2018

STSD-101.2 Rev 0 / 11-09-15


ALL ENTRIES/SIGNATURE IN THIS FORM MUST BE

ORIGINAL.

Attach recent 1" X 1"

picture here

Once officially stamped, DO NOT detach photo.

Attach another copy of the same 1" x 1"

picture for the Test Permit.

FORM A Instruction: The applicant must be the one to accomplish Form A and affix his/her signature together with one of his/her parents or legal guardian. Write clearly in the box provided or check the box for the appropriate answer. Avoid erasures. For any erasure, the applicant should countersign the item corrected along the page margin. PLEASE ANSWER ALL ITEMS.

Deadline for Submission: 25 August 2017 (Friday) Date of Examination: 15 October 2017 (Sunday) I. PERSONAL DATA

1. Name of Applicant Surname

2. Sex D Male D Female 3. Date of Birth

First Name Middle Name

4. Place of Birth

5. Citizenship I I 6. Do you have a dual citizenship? Oves D No If yes, please ~sp~e=c~ify.r:_: -===========::; 7. Contact Nos.: Landl,i~n~e~P~h~on~e:_:No~-~~======-1 ~C~e~II~P~h~o~ne~N~o.:... . .=1 =======~~8~-~E~m~a:ii~A::d~d~re~ss~::._::l ========~ 9.PermanentAddressL---~-------~--------~~~~~~-------~~----~~~

No. Street Barangay City/Municipality Province Zip Code

10. Number of Children in the Family D 11. Birth Order of Applicant (1st child, 2nd child, etc.) D 12 S · H" h S h I St d D DNON-STEM SchooiCodel . emor 1g c oo ran STEM (To be provided by oosr-sEIJ

~~--~~------------~~--~~~~========~====~ 13. Name of School

14. Type of School

15. Address of High School D

Regular Public High School D

Science High School D

Private High School

16. Tuition and Other School Fees Paid in a Private High School I p *Please att<Jch assessment form or statement of account provided by the L. ______ -.J

school. If under scholarship: indicate name of scholarship, amount of grant and submit certifiaJtion from school or foundaaon.

II. FAMILY DATA

Father

18. Name

19. Highest Educational Attainment

20. Occupation (pis. specify) 21. Name of Employer

22. Employer Address

23. 2016 Annual Gross Income (in pesos; taxable and non-taxable)

24. If self-employed, declare 2016 Annual Gross Income

25. Tribal Affiliation If applicable, please submit a certification of membership from the local Office of Muslim Affairs or National Commission on Indigenous People.

D University/College-based Senior High School

17. Have you been issued a passport? DYes DNo

~~===------===~~ If yes, please write the Passport No.

Legal Guardian Mother (To be accomplished ONLY by those whose

parents are deceased, working abroad, etc; should submit affidavit of auardianshiPi

I•

26. Is vour familv a beneficiarv of the DSWD's Pantawid Pamilvann Pilininn Prnnr;,m r 4Pc: n II Yt:oc: liNn

J.JJ., .:n .. nVLI\R:tnJt' U"t ll:rt I J.UA~ UA I A

27. Check appropriate box for scholarship program applied for:

D RA 7687 SCIENCE AND TECHNOLOGY SCHOLARSHIP For applicant who belongs to a family whose socio-economic status does not exceed the set values of ALL the identified indicators as approved by the Advisory Committee on S& T Scholarships.

D DOST-SEI MERIT SCHOLARSHIP For an applicant who belongs to a family whose socio-economic status exceeds the set values of any of the Identified indicators. Aoolicant must oav a non-refundable test fee of P200.00.

28. Have you applied for scholarship other than the DOST -SEI? Oves 0No

If yes, please identify which scholarship: DOWWA OcHED DGsis D Others, specify ____ _

.-----------------------------------------------~ 29. College/University where you intend to enroll :

Note: You are advised to take the admission test of the college/university where you intend to enroll in SY 2018-2019.

30. Test Center nearest your school:

Note: Please refer to the list of designated test centers in the 2018 S& T Scholarship announcement brochure. The scholarship examination will be administered on 15 October 2017 (Sunday) at an identified test center In your province.


Attested by:


FORM B- HOUSEHOLD INFORMATION QUESTIONNAIRE (HIQ)

A. HOUSEHOLD PROFILE

Signature of Applicant Date:

1. Profile of household members (Please include only the parents, applicant and applicant's siblings who are single, age 21 and below, live under the same roof and share in common food.) (Jbilang ang mga magulang, aplikante at mga kapatid ng aplikante na walang asawa, may edad 21 pababa, kasalukuyang nakatira sa bahay at kasama sa inihahain · pagkain.)

Name Relationship Age Civil Highest Grade or Occupation of Class of Gross Income for

(Put Household to Applicant Status Educational Year Working Worker the Year 2016

Head* as first in the (See Attainment Attending If Household (See codes (In pesos)

list; include name of codes (Specify grade, Currently In Member below) below) year or degree) School

applicant)

(1) (2) (3) (4) (5) (6) (7) (8) (9)

1.

2.

3.

4.

5.

6.

7.

8.

9 .

10.

11.

*Household head usually provides the chief source of Income for the family. He or she Is responsible for the organization and care of the household or the person who is regarded as such by the members of the household.

Codes for Col. 4 (civil status):

1 Single 2 Married 3 Widowed 4 Divorced/Separated 5 Unknown

Codes for Col. 8 (class of worker):

1 Works for private household 5 Employer in own family-operated farm/business 2 Works for private establishment 3 Works for government agency/corporation 4 Self-employed without any employee

(e.g., sari-sari store owner, dressmaker)

6 Works with pay on own family-operated farm/business 7 Works without pay on own family-operated farm/business 8 Unemployed (e.g. housewife)

2.a Annual Household Gross Income 2016 P L-------------------~

2.b If both parents are unemployed, do you have any rel~s other than those in the profile of household members (whether here or abroad) who contribute in meeting your family expenses? L_j Yes D No If yes, please accomplish the table below:

Nature of Financial Contribution Relationship of Contributor to Applicant Frequency of Contrlb0tlon Average Contribution (e. q., remittances) (e.g., brother who is an o.rWj ·(please mark with (In pesos)

( ) Monthly -

( ) Quarterly

( ) Every __ (no. of mos.)month

Paalala: • . Kung ang mga magulang ay may hanapbuhay (employed) o di kaya ay may sariling negosyo, magblgay ng kopya ng

Income Tax Return (ITR) o W- 2 para sa taong 2016. Kung walang hanapbuhay (unemployed) ang ama, magbigay ng kopya ng BIR Certification o Munlcipai/Barangay Certification of Indlgency o Exemption ng pag file ng ITR. Kung .ang ina ay "housewife", hindi na kallangang magsumite ng nasa bing sertlpikasyon.

FORMC

CERTIFICATE OF GOOD MORAL CHARACTER


This is to certify that has consistently maintained good moral character, there having no disciplinary action taken against him/her as of the date of application.

Printed Name & Signature of Principal/Guidance Counselor Date: ________________________________ ___

NOTE: Failure to maintain good moral character before the award of the scholarship shall cause forfeiture thereof. DOST-SEI may require another certification before the signing of the Scholarship Agreement should the applicant qualify.

FORM 0-1 For Applicant from the STEM Strand

PRINCIPAL'S CERTIFICATION


This is to certify that is a candidate for graduation of ----------;:-:---~-:----:-:::--:-:--:---------------for the SY 2017-2018.

(Name of School/Address)

FORM 0-2 For Applicant from the NON-STEM Strand

Name of High School Address


PRINCIPAL'S CERTIFICATION

Printed Name & Signature of Principal

Date:--------------

This is to certify that --'-------=------------------------,- is a candidate for graduation for the SY 2017-2018 and is classified within the upper five percent of graduating students.

total number

Note: Please certify based on applicant's academic standing as of grade 11 (i.e., top 5% of his/her class)

Printed Name & Signature of Principal

Date: --------------------------

FORM E {In case applicant has already graduated from high school in the previous year)

APPUCANT'S CERTIFICATION TO WHOM IT MAY CONCERN:

This is to certify that the undersigned has not taken any previous DOST-SEI Undergraduate Scholarship Examination and has not earned any post-secondary or undergraduate units.

Attested by: ---.,-----------::-c---,.--Printed Name & Signature of Parent or Guardian

FORM F

Printed Name & Signature of Applicant

Date: ----------------------------

PARENT'S CERTIFICATION

This is to certify that my son/daughter, ----------------------------~ has no pending application for immigration to the USA or any other country.

Printed Name & Signature of Parent

Date: ---------------------------

FORM G (For RA 7687 Applicants only)

CERTIFICATE OF RESIDENCY


This is to certify that ----------------------- is a bonafide resident of------------------------------for not less than 4 years.

Printed Name & Signature of Barangay Official/Principal Date:

FAMILY PROFILE (Continuation)

3. Ownership of the housing unit: (Indicate answer in the box provided) c=J 1 Owned, Fully Paid 2 Owned, Amortized 3 Rented 4 Rent free/living w/ relatives 5 Others, pis. specify __ _

If rented, how much is the monthly rental? I: /month' If amortized, how much is the monthly amortization? . /month

4. Owns hectares of agricultural or non-residential land? (area in sq. m) 0 None

5. Electric Consumption for the last three (3) months I kwh I I kwhl I kwh I (Note: Provide clear photocopies of the electrical bills.) 2017 L_ ____ 720:::-1:C:7~ 201"7

6. Does your family own any of the following appliances and vehicles?

No. of Working Units Appliance/Vehicle Mode of Acquisition

Aircondition

Make/Model Year Acquired

Movie camera

car/Van/Pajero/Other Similar Vehicle

Fleet of Jeepney or tricycle

!pad

Industrial Freezer

Industrial Dryer

7. Indicate name(s) of existing credit card of the family members, if any: -------------------

8 . CONTACT ADDRESS/NO. (Indicate as many as possible)

Mailing Address

Landline Phone No. Cell Phone No.

Applicant Parent or Legal Guardian 1----------lll 1----------i Fax No. Email Address

Submitted by:

Signature Over Printed Name of Applicant Date Signed

SIGNED DECLARATION BY THE PARENTS OR LEGAL GUARDIAN: 1/We hereby certify to the truthfulness and completeness of information provided. Any misinformation or withholding of information will automatically disqualify my/our child from the DOST-SEI Undergraduate Scholarship Program. !/we are also willing to refund all the financia l benefits received plus the appropriate interest if such misinformation is discovered after my/our child has accepted the award.

In connection with this application for scholarship, I/we hereby authorize the DOST-SEI designated representative to conduct a credit check on the family finances, including bank accounts, credit card accounts, SSS and GSIS accounts, and to visit our family dwelling.

Father's Signature Mother's Signature over printed name---------

or Legal Guardian's Signature

over printed name _________ _

over printed name----------

Date Signed: ________ _

For DOST SEIIRO STAFF USE ONLY

D

D D

D D D D

CHECKLIST OF DOCUMENTS SUBMITTED: Accomplished Forms:

I

DA DB oc 0D1 002 DE OF OG'

Photocopy of Birth Certificate

ParenVs 2016 Income Tax Return/W2/Employment Contract, if OFW or Clear photocopy of the 4Ps 10 or Municipal I Brgy. Certification that the applicant belongs to indigent family and his/her parents are exempted from filing of Income Tax Return Photocopy of the latest three consecutive months of electric bill for the Year 2017

Assessment fonm/statement of account from the private high school/scholarship certification•

Two recent pi~tures size, 1" x 1"

If affiliated with a particular tribe, certification of membership from the local Office of Muslim Affairs (OMA)/National Commission on Indigenous People (NCIP).

• For RA 7687 Applicants only

THIS APPLICATION FORM AND ATTACHED DOCUMENTS WERE

VERIFIED FOR COMPLETENESS BY:


OsEI D DOST RO. No.

Remarks:

Date:---- - ------ - -