to be filled-out by dost/sei staff only republic of the ......form b – household information...

TO BE FILLED-OUT BY DOST/SEI STAFF ONLY Republic of the Philippines Department of Science and Technology

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

NOT FOR SALE CAN BE REPRODUCED

ALL ENTRIES/SIGNATURE IN THIS FORM MUST BE ORIGINAL.

TCC APPLN. NO.

-

2018 Total Annual Family Gross Income:

(Taxable & Non-taxable) ₱ __________________

Ave. Electricity Consumption of 3 months:

____________ kwh

2019 JUNIOR LEVEL SCIENCE SCHOLARSHIPS

APPLICATION FORM

General Weighted Average: _________________

Ownership of Vehicle: _______________________

Scholarship Program Assessment:

MERIT P200.00/O.R. No. ____________

RA 7687

RA 10612

Assessed by: ____________________________ Once officially stamped, DO NOT detach photo. Attach another copy

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

Printed Name / Signature Deadline for Filing of Application: April 26, 2019

SEI DOST RO. No. ___ Schedule of Examination : June 2, 2019

FORM A – PERSONAL INFORMATION 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. PERSONAL DATA

Name of Applicant (Last Name, First Name, Middle Name, Suffix Name):

Date of Birth (MM/DD/YYYY):

/ / Place of Birth: Number of Children in the

Family: Birth Order of Applicant (1st child, 2nd child, etc.):

Sex:

Male Female

Mobile Phone No.: Email address: Citizenship:

Permanent Address (House/Unit No., Street, Lot/Blk, VIllage/Barangay): Do you have dual citizenship?

Yes No

If yes, please specify:

____________________

City/Municipality: Province: Zipcode: District: Have you been issued a passport?

Yes No

If yes, write the Passport No.:

____________________

S&T Program Enrolled in: DepEd Learner Reference Number:

Name of University/College: (Please spell-out the name and indicate campus, if applicable)

Address of University/College:

II. FAMILY DATA

Father Mother

Legal Guardian (To be accomplished ONLY by those whose parents are deceased, working

abroad, etc; should submit affidavit of guardianship)

Name

Contact Number

Highest Educational Attainment

Occupation (pls. specify)

Name of Employer

Employer Address

2018 Annual Gross Income (in pesos; taxable and non-taxable)

If self-employed, declare 2018 Annual Gross Income

Is your household included in the DSWD Listahanan 2.0? Yes No (If yes, please provide clear photocopy of your DSWD ID.)

Is your family a beneficiary of the DSWD’s Pantawid Pamilyang Pilipino Program (4Ps)? Yes No (If yes, please provide clear photocopy of your family’s 4Ps ID.)

III. 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 science, mathematics and technology in any of the secondary schools throughout the country.

Form A, C, D, E, G2, H,

and I

RA 7687 For an 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.

Form A, B, C, D, E, F, G1, H, and I

MERIT For an applicant who belongs to a family whose socio-economic status exceeds the set values of any of the identified indicators. Applicant must pay a non-refundable test fee of P200.00.

Form A, C, D, E, G1, H, and I

Attach recent

1” x 1”

photo here

STSD-101.2 Rev. 2 / 03-18-19

FORM B – HOUSEHOLD INFORMATION QUESTIONNAIRE (HIQ) (For RA 7687 Applicants only) I. HOUSEHOLD PROFILE

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.) / (Ibilang ang mga magulang, aplikante at mga kapatid ng aplikante na walang asawa, may edad 21 pababa, kasalukuyang nakatira sa bahay at kasama sa inihahaing pagkain.)

Name (Put Household Head* as first in the list; include

name of applicant)

Relationship to Applicant

Age Civil Status

(See codes below)

Highest Educational Attainment

(Specify grade, year or degree)

Grade or Year Attending if Currently in

School

Occupation of Working

Household Member

Class of Worker

(See codes below)

Gross Income for the Year

2018 (in pesos)

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

1.

2.

3.

4.

5.

6.

7.

8.

9.

*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. Total: ________________

Codes for Column 4 (civil status): S – Single M – Married W – Widowed D – Divorced/Separated U – Unknown

Codes for Column 8 (class of worker): A – Works for private household B – Works for private establishment C – Works for government agency/corporation D – Self-employed without any employee (e.g., sari-sari

store owner, dressmaker)

E – Employer in own family-operated farm/business F – Works with pay on own family-operated farm/business G – Works without pay on own family-operated

farm/business H – Unemployed (e.g. housewife)

II. FINANCIAL CONTRIBUTION

If both parents are unemployed, do you have any relative/s other than those in the profile of household members (whether here or abroad) who contribute in

meeting your family and school expenses? Yes No

Purpose of Financial Contribution (e.g., educational assistance)

Relationship of Contributor to Applicant (e.g., brother who is an OFW)

Frequency of Contribution (see codes below)

Annual Contribution (In pesos)

Codes for Column 3 (Frequency of Contribution): A – Monthly B – Quarterly C – Semi Annual D – Annual E – Irregular Total: ____________________

Total Annual Household Gross Income in 2018 (I. Household Profile + II. Financial Contribution) ₱______________________

Paalala:

Ang may sariling negosyo o/at ang mga kumikitang miyembro ng pamilya ay kailangang magbigay ng kopya ng Income Tax Return (ITR) o W-2 para sa taong 2018.

Kung ang taunang kita ng mga kumikita sa pamilya ay hindi lalagpas sa ₱250,000.00, magpasa ng kopya ng BIR Certification of Exemption ng pag file ng ITR.

Kung ang kumikita sa pamilya ay walang employer at ang taunang kita ay hindi lalagpas sa ₱250,000.00, magpasa ng kopya ng BIR Certification of Exemption ng pag file ng ITR o Certification of Indigency.

III. OTHER HOUSEHOLD INFORMATION

Electric Consumption for the last Three Months: Does your family share electricity with other families? Yes No If yes, please accomplish the Certificate of Electric Sharing

Month 1: kwh

Month 2: kwh

Month 3: kwh

CERTIFICATE OF ELECTRIC SHARING

This is to certify that ____________ families are sharing in the payment of electric bills under the name of _____________________

(No. of families sharing) ________________________________________________ with address _________________________________________________. They are paying the following amount:

Name of Family Heads* Amount (in pesos) Signature of

Family Heads

Certified True and Correct: ______________________________________ Printed Name & Signature of Barangay Official Date: _________________________________

Month 1 Month 2 Month 3

1.

2.

3.

4.

5. *indicate in the first number the name of applicant’s parent.

Ownership of the housing unit: If rented, how much is the monthly rental?

If amortized, how much is the monthly amortization?

Owned, Fully Paid

Owned, Amortized

Rented

Rent free/living with relatives

Others, pls. specify

Does your family own agricultural land or non-residential land? Yes No If yes, what is the lot area in square meters? ___________________ sq. m.

Does your family own vehicle/s? Yes No

Type No. of working units Year Model (ex. 2000, 2008) Make (ex. Honda, Suzuki, Toyota)

Tricycle

Passenger vehicle (e.g. Jeepney, Van, etc.)

Car/AUV/SUV

Truck/Bus

FORM C – CERTIFICATE OF GOOD MORAL CHARACTER

TO WHOM IT MAY CONCERN:

This is to certify that __________________________________________________________________ has consistently maintained (Name of Applicant) good moral character, there having no disciplinary action taken against him/her as of the date of application. _______________________________________________ Printed Name & 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 should the applicant qualify.

FORM D – CERTIFICATION OF GOOD HEALTH TO WHOM IT MAY CONCERN:

This is to certify that I have examined ____________________________________________ and found that he/she is FIT to study. (Name of Applicant) _______________________________________________ Doctor’s Printed Name & Signature

License No.: ____________________________________

Date: __________________________________________

FORM E – CERTIFICATION OF PROGRAM OF STUDY AND YEAR LEVEL


This is to certify that ________________________________________________________________________________ is enrolled in (Name of Applicant)

Bachelor of Science in _______________________________________________________________ as a REGULAR SECOND YEAR student (Program of Study) for Second Semester AY _____2018-2019____ at the ________________________________________________________________. (College/University) _______________________________________________ Printed Name & Signature of College Dean

Date: __________________________________________

NOTE: Potential qualifiers to the JLSS Scholarship Program will be required to submit a certification of Regular Third Year Standing in AY 2019-2020; proper notification will

be sent sometime in July – August 2019. Awarding of the scholarship shall be pending the submission of this requirement.

FORM F – CERTIFICATE OF RESIDENCY (For RA 7687 Applicants only)


This is to certify that ________________________________________________________________________ is a bonafide resident of (Name of Applicant) ____________________________________________________________ for not less than 4 years. (Permanent Address) _______________________________________________ Printed Name & Signature of Barangay Official/Principal Date: _________________________________________

FORM G1 – COMMITMENT TO RETURN OF SERVICE (For RA 7687 and MERIT Applicants only) This is to certify that the undersigned AGREES to render service in the country preferably along the field of specialization, on a full-time

basis for a minimum period equivalent to the duration of the scholarship.

Noted by: _____________________________________ _____________________________________

Printed Name & Signature of Parent Date: ______________________________________

Printed Name & Signature of Applicant Date: _________________________________________

FORM G2 – COMMITMENT TO RETURN OF SERVICE (For RA 10612 Applicants only) 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 soon after graduation as return service. In case of failure to comply with the terms of the Service Agreement, the undersigned

agrees to repay the amount disbursed for his/her scholarship, plus applicable interest.

Noted by: _____________________________________ _____________________________________



FORM H – APPLICANT’S CERTIFICATION

This is to certify that the undersigned has:

NOT taken any previous DOST-SEI examination. Taken the DOST-SEI Undergraduate Examination but did not qualify for the scholarship. Qualified for the DOST-SEI Undergraduate Scholarship but did not avail of the award.

Noted by: _____________________________________ _____________________________________



FORM I - SIGNED DECLARATION BY APPLICANT AND THE PARENTS/LEGAL GUARDIAN:

I/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. I/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, I/we 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, I/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, consult, use, consolidate, block, erase or destruct my personal data as part of my/our information. I/We 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 Over Printed name ________________

Or Mother’s Signature Over Printed name ________________

Or Legal Guardian’s Signature Over Printed name _______________

For DOST SEI/RO Staff use only : Checklist of Documents Submitted

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 D – Certification of Good Health

Form E – Certification of Program of Study and Year Level

Form F – Certificate of Residency (for RA 7687Applicants only)

Form G1 – Commitment to Return of Service (for RA 7687 and MERIT Applicants only) ____________________________

Form G2 – Commitment to Return of Service (for RA 10612 Applicants only) Printed Name/Signature

Form H – Applicant’s Certification

Form I – Signed Declaration by Applicant and the Parent/Legal Guardian

Official Transcript of Records (TOR) or Certified True Copy of Grades (TCG)

Two recent (1" x 1") pictures Date of Review of Documents: _____________

Photocopy of Birth Certificate

Photocopy of any document containing the DepEd Learner Reference Number

Parent/s 2018 Income Tax Return / W2 / Employment Contract for OFW / BIR Date of Return of Applicant: _____________

Certificate of Exemption for Filing of ITR / Municipal or Barangay Certificate of Indigency (for RA 7687Applicants only)

Electric Bills for the recent 3 consecutive months (for RA 7687 Applicants only) Remarks:

Affidavit of guardianship (If with legal guardian)

Others: ______________________________________________________

S&T Programs Covered by the DOST-SEI Undergraduate Scholarships

Aeronautical Engineering Computer Engineering Marine Biology

Aerospace Engineering Computer Science Marine Science

Agribusiness Management Doctor of Veterinary Medicine Materials Engineering

Agricultural and Biosystems Engineering

Electrical Engineering Mathematics

Agricultural Biotechnology1 Electronics and Communications Engineering/Electronics Engineering

Mathematics and Science Teaching

Agricultural Chemistry Environmental Science Mathematics Teaching

Agricultural Economics Fisheries Mechanical Engineering

Agricultural Engineering Food Technology Mechatronics Engineering

Agricultural Technology Forestry Medical Laboratory Science/Medical Technology

Agriculture Geodetic Engineering Metallurgical Engineering

Animal Science Geography Meteorology

Applied Mathematics Geology Microbiology

Applied Mathematics major in Mathematical Finance2

Geothermal Engineering Mining Engineering

Applied Physics Health Science Molecular Biology and Biotechnology

Applied Physics with Applied Computer System

Human Biology

Nutrition

Applied Physics with Materials Science and Engineering

Industrial Design Nutrition and Dietetics

Applied Statistics Industrial Engineering Packaging Engineering

Astronomy Technology Industrial Management Engineering-Information Technology3

Petroleum Engineering

Bachelor of Library and Information Science

Industrial Pharmacy Pharmaceutical Sciences

Bachelor of Secondary Education major in Science

Information and Communications Technology

Pharmacy (4-year program)

Biochemistry Information System Pharmacy major in Clinical Pharmacy (5-year program)

Biology Information Technology Physics

Ceramics Engineering Information Technology Systems Psychology4

Chemical Engineering Instrumentation and Control Engineering

Public Health

Chemistry Life Sciences

Science Teaching (Biology, Chemistry, Physics, Physical Science, Biology and Chemistry)

Chemistry with Applied Computer Systems

Management Information Systems2

Statistics

Chemistry with Materials Science and Engineering

Manufacturing Engineering

Civil Engineering Manufacturing Engineering-Management-Biomedical Engineering3

1at UP System only 24 yrs, ADMU 3at DLSU only 4BS Program

Community Nutrition Manufacturing Engineering-Management-Mechatronics and Robotics3

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CONDITION

STUDY PLACEMENT

STUDY PLACEMENT

State Universities and Colleges (SUC)

CHED identified Centers of Excellence (COE) or Centers

of Development (COD)* on the S&T programs covered

under the DOST-SEI Undergraduate Scholarships

Institutions with FAAP Level III Accreditation** on the

S&T programs covered under the DOST-SEI

Undergraduate Scholarships

*refer to https://ched.gov.ph/memorandum-orders/ for the

recognized universities per identified program

**refer to http://paascu.org.ph/?page_id=119 for the

universities with accreditation

RETURN SERVICE

CONDITION

Upon completion of the S&T program, the scholar-graduate

shall return service in the country on a full-time basis,

preferably in his/her home region, and preferably along

his/her field of specialization, for a minimum period

equivalent to the length of time he/she enjoyed the

scholarship.

RA 10612 The scholarship program under Republic Act No.

10612 aims to strengthen the country’s science

and technology education by fast-tracking

graduates in the sciences, mathematics and

engineering who shall teach science and

mathematics in secondary schools throughout the

country.

RA 7687

Scholarships under the Republic Act No. 7687 are

awarded to poor, talented and deserving students

who belong to families whose socio-economic

status do not exceed the set values of certain

indicators.

MERIT

The DOST-SEI MERIT scholarships are awarded to

students with high aptitude in science and

mathematics and are willing to pursue careers in

the fields of science and technology.

Types of Scholarships

Upon completion of the S&T course, the scholar-graduate

shall teach full time high school subject/s, namely:

Agricultural

Aquaculture

Biology

Chemistry

Fisheries Technology

Information Technology

Mathematics

Physics

In any school, public or private, within the country, with

first priority in his/her home province for a minimum

period of two (2) years.

State Universities and Colleges (SUC)

Other private universities or colleges that are with

CHED-compliant programs

2019

Scholarships Junior Level Science

https://ched.gov.ph/memorandum-orders/http://paascu.org.ph/?page_id=119

A. General Criteria of Eligibility RA 10612 RA 7687 MERIT

natural-born Filipino citizen;

poor, talented and deserving student who belongs to a family whose socio-economic status does not exceed the set values of certain indicators;

regular 2nd year college student in an identified S&T program for Second Semester of AY 2018-2019

has a general weighted average (GWA) of at least 83% or its equivalent in his/her first year and the first semester of the second year in college

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 2019 JLSS Examination

B. Scholarship Privileges

Tuition and other school fees P40,000.00 per Academic Year

Book Allowance P10,000.00 per year

Group Insurance Premium

Transportation Allowance (for those studying outside of home province)

1 economy-class roundtrip fare

Monthly Living Allowance P7,000.00 per month

Summer Allowance (if required per curriculum)

Tuition and other school fees

P1,500.00

Book Allowance P500.00 (to submit O.R.)

Monthly Allowance P7,000.00 per month for 2 months

Post –graduation clothing allowance P1,000.00

C. Items to be Submitted

Form A: Personal Information

Form B: Household Information Questionnaire (For RA 7687 only)

Form C: Certificate of Good Moral Character

Form D: Certificate of Good Health

Form E: Certification of Program of Study and Year Level (2nd Year Second Semester in AY 2018-2019)

(Potential qualifiers to the JLSS Scholarship Program will be required to submit a certification of regular Third Year Standing in AY 2019-2020; proper notification will be sent sometime in July – August 2019. Awarding of the scholarship shall be pending the submission of this requirement.)

Form F: Certificate of Residency (For RA 7687 only)

Form G1: Commitment to Return of Service (For RA 7687 and MERIT)

Form G2: Commitment to Return of Service (For RA 10612 only)

Form H: Applicant’s Certification

Form I: Signed Declaration

Official Transcript of Records (TOR) or True Copy of Grades (TCG) for the first year and the first semester of the second year in college

Two recent (1”x1”) pictures

Photocopy of Birth Certificate

Photocopy of any document containing your DepEd Learner Reference Number (High School Diploma, Form 137, etc.)

Parent/s 2018 Income Tax Return / W2 / Employment Contract for OFW / BIR Cert. of Exemption from Filing of ITR / Brgy. Cert. of Indigency (for RA 7687 only)

Electric bills for the recent 3 consecutive months (for RA 7687 only)

Non-refundable test fee of P200.00 (for MERIT only) a

Who may APPLY?

Applicants in regular second year standing for the second semester of AY 2018-2019

who meets eligibility requirements of the JLSS and the following conditions:

Have not taken any previous DOST-SEI examination; or

Have taken the DOST-SEI Undergraduate Examination but did not qualify for

the scholarship; or

Qualifier of the DOST-SEI Undergraduate Scholarship but did not avail of the

award

Who should NOT apply anymore?

Students whose DOST-SEI Undergraduate Scholarship were terminated

D. Where to Secure / File Application

The application form 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 the website, www.sei.dost.gov.ph.

Accomplished form can be filed at the Science Education Institute, or DOST Regional Office/PSTC nearest the applicant’s school or home address.

The test permit shall be mailed to the applicant. In case the test permit is not received within the week before the examination day, the applicant may inquire from the DOST Regional Office/PSTC and check the nearest designated test center a day before the examination

E. Test Fee

For Merit applicants, a non-refundable test fee of P200.00 will 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 only accept cash, postal money orders, telegraphic transfer, certified cashier’s and manager’s check. PERSONAL CHECKS ARE NOT ACCEPTABLE.

F. Selection Criteria The awardees shall be selected on the basis of their performance in the 2019 Junior Level Science Scholarship Examination.

G. Final Selection

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

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, 837-2071 loc. 2382 www.sei.dost.gov.ph

Deadline for Filing of Application:

April 26, 2019 Date of Examination:

June 2, 2019
http://www.sei.dost.gov.ph/