ere eee nd Republic of the Philippines cere 7G APP, NO. Department of Science and Technology eee I | J ETT since ‘SCIENCE EDUCATION INSTITUTE cane ERNE (Taxable & Nontaxable) Pe P.O. Box 18 Taguig Post Office A AAhENTRESSIGNATURE 1 ‘vq, Electity Consumption for months Anal HS Net Tuton & Otter Sol Fees. 2019 DOST-SEI Attach recent erect ssesamen SCIENCE AND TECHNOLOGY vx Scholarship Program Assessment F maser UNDERGRADUATE SCHOLARSHIPS photo here MERIT 200.000 No APPLICATION FORM Once official stamped DO NOT detach shat Printed Name/Signaiure | Deadline for Filing of Application: August 31, 2018 Attach another copy stl DST RO. No. ‘chedule of Examination \ctober of the same 1" x1" photo [J se: _| posto No. __ | Schedule of €: ti ‘October 21, 2018 Te the Tost Borat Ee rnrectod along I. PERSONAL DATA Asvessod by Name of Applicant ssf ans, Frs Nae Suh fone) Date of Birth iwwonwvy) | Place of Birth Number of Children in the | Birth Order of Applicant chs ets wie) / Family Sex Mobile Phone No. Email address: Citizenship Male OFemale Permanent Addross House Lot | Tyee ears | | Ne ‘Type of School ‘Senior High School Strand rogue Po Cseenca tis Cervatenis Cl unverstcaen UisTem —CINON-STEM Name of Schoo! Tuition and Other School Fees Paid in a Private High Schoo! ‘Address of Schoo}: 1, FAMILY DATA Father Mother Name Highest Educational Attainment Occupation ins secciy Name of Employer Employer Address 201 If seltemployed, declare 2017 Annual Gross Income Is your household included in the DSWD Listahanan 2.07 Yes ONo Is your family a beneficiary of the DSW wid Pamilyang Pilipino Program (4Ps)? Yes — ONo TIT. SCHOLARSHIP INTENTIONS DATA Check apprnpate bo 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 identifed indicators as approved by the Advisory Commitee on SAT Scholarships. otarship program apples far DOST-SEI MERIT SCHOLARSHIP For an applicant who belongs to a family whose socio-economic statu Applicant must pay a non-refundable test fee of P200,00. (ceeds the set values of any of the identified indicators,FORM B — HOUSEHOLD INFORMATION QUESTIONNAIRE (HIQ) I. HOUSEHOLD PROFILE Profle of housenold members (Please meluae ony the parents, applicant and applicant's Sbiags who are single. ago 27 and below, Wve undor tho same roo! and share in commen ooo} / lang ang mga magulang, apikante at mga kapaté ng aplkante na walang asa, may edad 21 pababs, Kasalukuyang nakatra sa bahay at kasama sa ininaany oagkai.) Name Relationship] Age| Civil | Highest | Grade or Year | Occupation of | Glass of | Gross Income iavosaraefretinihe tet ncuse | ta Applicant Status Educational | Attending i | Working | Worker | for the Year ome of aon Attainment | Currentlyin | Household | (See | 2047 in pesos) E285 | eety gree, |” Schoo! Member | se 1 2 4 6 Z a 6 “rae ic ta la of ere ome oar ore can oc a Raha] STShae for pate Housed ~ Employer n oun family pets tamitusress UsUnerown “sore onner aresamatory H-Unempioyed (eg houssufe) . FINANCIAL CONTRIBUTION IF Goth parents are unemployed, do you have any relates other than those inthe profile of household members (whether hare or abroad) who conf meeting your foray and seca! expenses? LI¥es LINO. Purpose of Financial Contribution Relationship of Gontributorto Applicant | Frequency of Contribution | Annual Contribution ie. edventona eestor) Ye bother whos sn OPM one ses blo nese Codes for Colum 3 (Funny of Canintans A= Worthy B-uately—C-Sem Annual Donal C= Inegusr Total | Paaiata ‘+ Kung ang mga magulang ay may hanapbuhay (employed) 0 di aya ay may sarling negosyo, magbigay ng kopya ng Income Tax Return (TR) 0 We2 para'sa taong 2017. ‘+ Kung walang hanapbuhay (unemployed) ang ama, magbigay ng kopya_ng BIR Certification © Muni Exemption ng pag file ng ITR. + Kung ang ina ay "housewife, hindi na kailangang magsumite ng nasabing sertipikasyon, ipalBarangay Certitication of Indigency 0 IIT. OTHER HOUSEHOLD INFORMATION Electric Consumption forthe last Three Months: oes you ary shave wa Loves" CINo uh ‘ keh hn CERTIFICATE OF ELECTRIC SHARING This isto certify that families are sharing in the payment of electric bills under the name of with address ‘They are paying the following amount ‘Amount fn poses) ‘Signature of | Cortiiod True and Correct: Name of Family Heads” Monti | Month? — Monih3_| Family Heads Prted Name & Signature of Barangay Ofical OnePreys Uk erat TO WHOM IT MAY CONCERN: This is to certify that has consistenty maintained good moral character, ne date of application nere having no disciplinary action taken against himvher as of Printed Name & Signature of PrncipallGuidance Counselor Date TO WHOM IT MAY CONCERN This i 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: ee ea ote e ete OLE ide ene oe ee eed TO WHOM IT MAY CONCERN, under the This is to certify that is a candidate for the Grade 12 gradu: ;duation for the SY 2018-2019 and is classified within the upper five percent of graduating class. NON-STEM Stran ted Name & Signature of Principal Dat ee aoe ase applicant has already graduated from i 2 previous year) TO WHOM IT MAY CONCERN: This is to certify that the undersigned has not taken any previous DOST-SE! Undergraduate Scholarship Examination and has not ‘any past secondary or u Printed Name & Signature of Printed Name & Signature of Parent or Guardian Date eee This is to certty that my sonidaughter, has no pending application for immigration tothe USA 0° any other country Ware o Aone Printed Name & Signature of Parent Date [rece pO Dads a ‘TO WHOM IT MAY CONCERN, is a bonafide resident of This i to certify that for not less than 4 years. “Printed Name & Signature of Barangay OffcaliPrnapal Date: