2020 DOST-SEI Science and Technology Undergraduate Scholarships Application Form
2020 DOST-SEI Science and Technology Undergraduate Scholarships Application Form
2020 DOST-SEI Science and Technology Undergraduate Scholarships Application Form
1
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.
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.
Name
Contact Number
Highest Educational Attainment
Occupation (pls. specify)
Name of Employer
Employer Address
2018 Annual Gross Income
(in pesos; taxable and non-taxable)
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.)
RA 7687 SCIENCE AND TECHNOLOGY SCHOLARSHIP
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.
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.
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)
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.
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.
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
This is to certify that I have examined and found that he/she is FIT to study.
(Name of Applicant)
This is to certify that is a candidate for the Grade 12 graduation under the
(Name of Applicant)
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)
This is to certify that the undersigned has (Check all that apply):
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:
Printed Name & Signature of Parent or Guardian Printed Name & Signature of Applicant
Date: Date:
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
INSTRUCTIONS:
Name of Applicant:
S& T Programs Covered Under the DOST - SEI
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.
Undergraduate Scholarships
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
Agriculture Doctor of Veterinary Medicine Life Sciences Petroleum Engineering
Ra 7687
(to be filled up by DOST)