TO BE FILLED-OUT BY DOST/SEI STAFF ONLY STSD-101.

1
Republic of the Philippines Rev. 2 / 07-02-19
TCC APPLN. NO. Department of Science and Technology
- SCIENCE EDUCATION INSTITUTE NOT FOR SALE
CAN BE REPRODUCED
2018 Total Annual Family Gross Income: P.O. Box 18 Taguig Post Office ALL ENTRIES/SIGNATURE IN
(Taxable & Non-taxable) ₱ __________________ THIS FORM MUST BE ORIGINAL.
Ave. Electricity Consumption
____________ kwh
for 3 months:
Annual HS Net Tuition &
Other School Fees: ₱ __________________ 2020 DOST-SEI Attach recent
Ownership of Vehicle: _______________________
Scholarship Program Assessment: SCIENCE AND TECHNOLOGY 1” x 1”
RA 7687 UNDERGRADUATE SCHOLARSHIPS photo here
MERIT P200.00/O.R. No. _____________ APPLICATION FORM
Once officially stamped,
Assessed by: ____________________________
DO NOT detach photo.
Printed Name / Signature Deadline for Filing of Application: September 6, 2019 Attach another copy
SEI DOST RO. No. ___ Schedule of Examination : October 20, 2019 of the same 1” x 1” photo
for the Test Permit.

FORM A – PERSONAL INFORMATION

Instruction: Write clearly in CAPITAL LETTERS your personal information 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): DepEd Learner Reference Number:

Date of Birth (MM/DD/YYYY): Place of Birth: Number of Children in the Birth Order of Applicant (1st child, 2nd child, etc.):
Family:
/ /
Sex: Mobile Phone No.: Email address: Citizenship:
Male Female

Permanent Address (House/Unit No., Street, Lot/Blk, VIllage/Barangay): Do you have dual If yes, please specify:
citizenship?
Yes No ____________________
City/Municipality: Province: Zipcode: District: Have you been issued a If yes, write the Passport No.:
passport?
Yes No ____________________
Type of School: Senior High School Strand:
 Regular Public HS  Science HS  Private HS  University/College-based Senior HS STEM NON-STEM
Name of School: Annual Tuition and Other School Fees

₱_________________________________________________
*Please attach Assessment Form or Statement of Account provided by the
Address of School: school. If with scholarship or a voucher recipient, also submit a
certification from school or foundation indicating the name of scholarship
and amount of grant.

II. FAMILY DATA

Legal Guardian
(To be accomplished ONLY by those
Father Mother 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:

 For
RA 7687 SCIENCE AND TECHNOLOGY SCHOLARSHIP
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.

 For
DOST-SEI MERIT SCHOLARSHIP
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 B – HOUSEHOLD INFORMATION QUESTIONNAIRE (HIQ)
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 Relationship Age Civil Highest Grade or Year Occupation of Class of Gross Income
(Put Household Head* as first in the list; include to Applicant Status Educational Attending if Working Worker for the Year
name of applicant) (See Attainment Currently in Household (See 2018 (in pesos)
codes (Specify grade, School Member codes
below) year or degree) below)
(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): Codes for Column 8 (class of worker):
S – Single A – Works for private household E – Employer in own family-operated farm/business
M – Married B – Works for private establishment F – Works with pay on own family-operated farm/business
W – Widowed C – Works for government agency/corporation G – Works without pay on own family-operated
D – Divorced/Separated D – Self-employed without any employee (e.g., sari-sari farm/business
U – Unknown store owner, dressmaker) H – Unemployed (e.g. housewife)

II. FINANCIAL CONTRIBUTION

If both parents are unemployed, do you have any sibling/s or relative/s other than those named in the (I.)Household Profile (whether here or abroad) who
contribute in meeting your family and school expenses? Yes No
Purpose of Financial Contribution Relationship of Contributor to Applicant Frequency of Contribution Annual Contribution
(e.g., educational assistance) (e.g., brother who is an OFW) (see codes below) (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 nakatakda (no fixed income), magpasa ng kopya ng BIR Certification of Exemption ng pag file ng ITR.
 Kung ang kumikita sa pamilya ay walang employer, 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
Month 1: Month 2: Month 3:
kwh kwh kwh If yes, please accomplish the Certificate of Electric Sharing

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:
Amount (in pesos) Signature of Certified True and Correct:
Name of Family Heads*
Month 1 Month 2 Month 3 Family Heads
1.
2.
3.
4. ______________________________________
Printed Name & Signature of Barangay Official
5. Date: _________________________________
*Indicate in the first number the name of applicant’s parent.

Ownership of the housing unit: If rented, how much is the If amortized, how much is the
monthly rental? monthly amortization?
Owned, Fully Paid Rented Others, pls. specify
Owned, Amortized Rent free/living with relatives
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 good moral character,

(Name of Applicant)
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 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)

_________________________________________________
Medical Doctor/School Physician’s Printed Name & Signature
License No.: ______________________________________
Date: ____________________________________________

FORM E1 – PRINCIPAL'S CERTIFICATION (For Applicant from the STEM Strand)

TO WHOM IT MAY CONCERN:

This is to certify that _________________________________________________ is a candidate for the Grade 12 graduation under the
(Name of Applicant)

STEM Strand of the ______________________________________________________________________ for the SY 2019-2020.

(Name of School/Address)

_______________________________________
Printed Name & Signature of Principal
Date: __________________________________

FORM E2 – PRINCIPAL'S CERTIFICATION (For Applicant from the NON-STEM Strand)

TO WHOM IT MAY CONCERN:

This is to certify that_________________________________________________ is a candidate for the Grade 12 graduation under the
(Name of Applicant)

NON-STEM Strand for the SY 2019-2020 and is classified within the upper five percent of ____________ students in the graduating class.
(Total Number of Graduating Students)

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

TO WHOM IT MAY CONCERN:

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 G – PARENT'S CERTIFICATION

This is to certify that my son/daughter, _________________________________________________, has no pending application for

immigration to the USA or any other country. (Name of Applicant)

_______________________________________
Printed Name & Signature of Parent
Date: __________________________________
FORM H – APPLICANT'S CERTIFICATION

This is to certify that the undersigned has (Check all that apply):

NOT taken any previous DOST-SEI Undergraduate Scholarship 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.

NOT earned any post-secondary or undergraduate units.

Noted by: _____________________________________ _______________________________________

Printed Name & Signature of Parent or Guardian Printed Name & Signature of Applicant
Date: __________________________________ Date: __________________________________

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 Science and Technology Undergraduate 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 for the
preparations of the publication of the list of scholarship qualifiers and as inputs for decision making in policy formulation relative to the
DOST-SEI scholarship programs. 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 Mother’s Signature Legal Guardian’s Signature

Or Or
Over Printed name ________________ Over Printed name ________________ 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 E1 – Principal’s Certification (For Applicant from the STEM Strand)
Form E2 – Principal’s Certification (For Applicant from the NON-STEM Strand)
Form F – Certificate of Residency (For RA 7687 Applicants only) ____________________________
Form G – Parent’s Certification (If no pending application for immigration) Printed Name/Signature
Form H – Applicant’s Certification
Form I – Signed Declaration by Applicant and the Parent/s/Legal Guardian
Two recent (1" x 1") pictures Date of Review of Documents: _____________
Photocopy of Birth Certificate
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 3 consecutive months in 2019 (for RA 7687 Applicants only) Remarks:
Affidavit of guardianship (If with legal guardian)
Certificate of scholarship in high school (If applicable)
High School Statement of Account (If applicable)
Others: ______________________________________________________
TCC/ Application No.: ___________________ (to be filled up by DOST)

Name of Applicant: ______________________________________________________________________________________

2020 DOST-SEI S&T Undergraduate Scholarship

(Detachable Label)

INSTRUCTIONS:
S &T P rograms Cove re d Unde r the DOS T -S EI

6. When your application is in order, you will be issued a Test Permit and a Primer.

5. Submit the brown envelope with the complete requirements to DOST-SEI; or the DOST Regional Office or the Provincial
4. Fill-out the detachable label below and paste it on the upper left hand corner of the long brown envelope.
3. Put the accomplished Application Form and all the documentary requirements in a long brown envelope.
2. Accomplish the Application Form completely with the necessary signatures.
1. Make sure you have read the attached brochure about the DOST-SEI S&T Undergraduate Scholarship Programs.
Unde rgra dua te S cholar ships

Science and Technology Center nearest you on or before 6 September 2019.

Medical Laboratory Science/Medical
Aeronautical Engineering Ceramics Engineering Industrial Design
Technology
Aerospace Engineering Chemical Engineering Industrial Engineering Metallurgical Engineering
Science and Technology
Industrial Management Engineering-
Agribusiness Management Chemistry
Information Technology3
Meteorology
Undergraduate Scholarships
Agricultural and Biosystems Chemistry with Applied Computer
Industrial Pharmacy Microbiology
Engineering Systems

Types of
Chemistry with Materials Science and Information and Communications
Agricultural Biotechnology1 Mining Engineering
Engineering Technology
Agricultural Chemistry Civil Engineering Information System Molecular Biology & Biotechnology

Scholarships
Agricultural Economics Community Nutrition Information Technology Nutrition
Agricultural Engineering Computer Engineering Information Technology Systems Nutrition and Dietetics
Agricultural Technology Computer Science Instrumentation and Control Eng’g. Packaging Engineering

Ra 7687
Agriculture Doctor of Veterinary Medicine Life Sciences Petroleum Engineering
Animal Science Electrical Engineering Management Information Systems2 Pharmaceutical Sciences
Electronics and Communications Republic Act No. 7687, also known as the “Science and
Applied Mathematics Manufacturing Engineering Pharmacy (4-year program)
Engineering/Electronics Engineering Technology Scholarship Act of 1994”, provides for scholar-
Manufacturing Engineering- ships to talented and deserving students whose families’
Applied Mathematics major in Pharmacy major in Clinical Pharmacy socio-economic status do not exceed the set cut-off values
Environmental Science Management-Biomedical
Mathematical Finance2 (5-year program) of certain indicators. Qualifiers must pursue priority fields
Engineering3
of study in the basic sciences, engineering, other applied
Manufacturing Engineering- sciences, and science and mathematics teaching.
Applied Physics Fisheries Management-Mechatronics and Physics
Robotics3
Applied Physics with Applied
Food Technology Marine Biology Psychology4
Computer System
Applied Physics with Materials
Science and Engineering
Forestry Marine Science Public Health
merit
Science Teaching (Biology, The DOST-SEI Merit Scholarship Program, formerly known
Applied Statistics Geodetic Engineering Materials Engineering Chemistry, Physics, Physical Science, as the NSDB or NSTA Scholarship under RA No. 2067, is
Biology and Chemistry) awarded to students with high aptitude in science and
mathematics and are willing to pursue careers in the fields
Astronomy Technology Geography Mathematics Statistics of science and technology.
Bachelor of Library and Information
Geology Mathematics and Science Teaching
Submit

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Geothermal Engineering Mathematics Teaching
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Biochemistry Health Science Mechanical Engineering
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RETURN OF SERVICE CONDITION  State Universities and Colleges (SUC)

 CHED identified Centers of Excellence (COE) or Centers of
Upon completion of the S&T program, the scholar-graduate shall render return service in the country on a full-time basis,
Development (COD) for the S&T programs covered under
preferably in his/her home region, and preferably along his/her field of specialization, for a minimum period equivalent to
the DOST-SEI Undergraduate Scholarships
the length of time he/she enjoyed the scholarship.
 Institutions with FAAP Level III Accreditation
 A. General Criteria of Eligibility RA 7687 MERIT D. Examination Coverage
 Natural-born Filipino citizen;   This scholarship examination is designed to measure abilities that determine academic and professional
 Poor, talented and deserving student who belongs to a family whose socio- success in science, technology, engineering, and mathematics. The test includes the following domains:
  Logical Reasoning, Science, Mathematics, English, Mechanical-Technical and a Self-Inventory.
economic status does not exceed the set values of certain indicators;
 Member of the STEM Strand senior high school graduating class; OR E. Selection Criteria
 Member of the top five percent (5%) of the Non-STEM Strand senior high  
school graduating class; The awardees shall be selected on the basis of their performance in the 2020 S&T Undergraduate Scholarship
Examination.
 Resident of the municipality for the last 4 years as attested by the barangay
 
chairman;
F. Final Selection
 Of good moral character and in good health; and  
The list of awardees as approved and announced by the DOST Secretary is final and unappealable.
 Qualifier of the 2020 S&T Scholarship Examination  
B. Scholarship Privileges G. Terms and Conditions
Tuition and other school fees P40,000.00 per Academic Year a) An awardee must seek admission in any of the S&T programs covered under the DOST-SEI Undergraduate
Book Allowance P10,000.00 per year Scholarships in any of the following:
a.1 State universities and colleges.
MS/PE uniform (1st Semester of First Year only) P1,000.00 a.2 Tertiary institutions identified as Centers of Excellence or Centers of Development by CHED or Level III
Group Insurance Premium accredited by FAAP for the S&T programs covered under the DOST-SEI Undergraduate Scholarships.
a.3 DOST-SEI identified network institutions.
Transportation Allowance (for those studying outside of home province) 1 economy-class roundtrip fare
He/She should pass the qualifying examination for admission to the university where he/she
Monthly Living Allowance P7,000.00 per month
plans to enroll in.
Summer Allowance (if required per curriculum)
P1,500.00 b) An awardee shall comply with the terms of the Scholarship Agreement to be entered into between himself/
 Tuition and other school fees
herself, parents or legal guardian and the DOST-SEI.
 Book Allowance P500.00 (to submit O.R.) c) After signing the Scholarship Agreement, the awardee’s name shall be included in the lists of scholars
 Monthly Allowance 2 months needing clearance from DOST-SEI forwarded to the appropriate government agency/ies for tracking
purposes.
Graduation clothing allowance P1,000.00 d) An awardee shall maintain the grade requirements of the scholarship.
e) Scholarship qualifiers who come from the non-STEM Strand, may avail of the scholarship effective the First
C. Items to be Submitted Semester of AY 2020-2021 as long as they are admitted in any of the S&T programs covered under the
 Form A: Personal Information   DOST-SEI Undergraduate Scholarships in a university that meets the study placement requirement.
 Form B: Household Information Questionnaire  
 Form C: Certificate of Good Moral Character   H. Securing / Filing Application
 Form D: Certificate of Good Health    The application form can be obtained at the Science Education Institute, 2nd Level, Science Heritage Bldg.,
 Form E1: Principal’s Certification that applicant belongs to the senior high 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
school STEM strand Class
downloaded at www.sei.dost.gov.ph.
 Form E2: Principal’s Certification that applicant belongs to the upper 5% of
 
the NON-STEM strand senior high school graduating class  Accomplished form can be filed at the Science Education Institute, or DOST Regional Office/PSTC nearest
the applicant’s school or home address.
 Form F: Certificate of Residency  
 Form G: Parent’s Certification  
Deadline for Filing of Application: Date of Examination:
 Form H: Statement of applicant that he/she has not taken any previous
DOST-SEI Undergraduate Scholarship Examination and any undergraduate
units or post secondary course (In case applicant has already graduated
  September 6, 2019 October 20, 2019
from senior high school)
 Form I: Signed Declaration by Applicant and the Parent/Legal Guardian    The Test Permit shall be mailed to the applicant/s 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
 Two recent (1”x1”) pictures   from the DOST Regional Office / PSTC and check the nearest designated test center a day before the
 Photocopy of Birth Certificate   examination.
 Parent/s 2018 Income Tax Return / W2 / Employment Contract for OFW / Department of Science and Technology
 
BIR Cert. of Exemption from Filing of ITR / Brgy. Cert. of Indigency SCIENCE EDUCATION INSTITUTE
 Electric bill for the recent 3 consecutive months   1st and 2nd Levels, Science Heritage Bldg.,
DOST Compound, General Santos Ave., Bicutan, Taguig City
 Non-refundable test fee of P200.00   Contact nos. (02) 839-0083, (02) 837-1333, 837-2071 loc. 2382
www.sei.dost.gov.ph