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1
TO BE FILLED-OUT BY DOST/SEI STAFF ONLY Republic of the Philippines
Rev. 2 / 07-02-19
TCC APPLN. NO.
- Department of Science and Technology
2018 Total Annual Family Gross Income: SCIENCE EDUCATION INSTITUTE NOT FOR SALE
CAN BE REPRODUCED
(Taxable & Non-taxable) ₱ __________________ P.O. Box 18 Taguig Post Office ALL ENTRIES/SIGNATURE IN
Ave. Electricity Consumption ____________ kwh THIS FORM MUST BE ORIGINAL.
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
MERIT P200.00/O.R. No. _____________ UNDERGRADUATE SCHOLARSHIPS photo here
Assessed by: ____________________________ APPLICATION FORM
Once officially stamped,
Printed Name / Signature Deadline for Filing of Application: September 6, 2019 DO NOT detach photo.
SEI DOST RO. No. ___ Attach another copy
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)
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 Total: ________________
the person who is regarded as such by the members of the household.
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 – MonthlyB – QuarterlyC – Semi AnnualD – AnnualE – 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:
Name of Family Heads* Amount (in pesos) Signature of Certified True and Correct:
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
If yes, what is the lot area in
Does your family own agricultural land or non-residential land? Yes No
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
(Name of Applicant)
TO WHOM IT MAY CONCERN:
_______________________________________________
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.
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: ____________________________________________
This is to certify that _________________________________________________ is a candidate for the Grade 12 graduation under the
(Name of Applicant)
_______________________________________
Printed Name & Signature of Principal
Date: __________________________________
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: __________________________________
_______________________________________________
Printed Name & Signature of Barangay Official/Principal
Date: _________________________________________
_______________________________________
Printed Name & Signature of Parent Date:
__________________________________
FORM H – APPLICANT'S CERTIFICATION
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.
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 Or Mother’s Signature Or Legal Guardian’s Signature
________________
Over Printed name Over Printed name ________________ Over Printed name _______________
INSTRUCTIONS
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Aerospace Engineering Chemical Engineering Industrial Engineering Metallurgical Engineering
Label)
S&TS
Undergraduate Scholarships
Agribusiness Management Chemistry Industrial Management Engineering- Meteorology
Information Technology3
EI
Agricultural and Biosystems Chemistry with Applied Computer Industrial Pharmacy Microbiology
Engineering Systems
ScholarshipUndergraduat
Types of
Agricultural Biotechnology1 Chemistry with Materials Science and Information and Communications Mining Engineering
Engineering Technology
DOST)byupfilledbe(to:.NoApplicationTCC/
Agricultural Chemistry Civil Engineering Information System Molecular Biology & Biotechnology
Agricultural Economics Community Nutrition Information Technology Nutrition
Agricultural Engineering
Agricultural Technology
Computer Engineering
Computer Science
Information Technology Systems
Instrumentation and Control Eng’g.
Nutrition and Dietetics
Packaging Engineering
Scholarships
Agriculture Doctor of Veterinary Medicine Life Sciences Petroleum Engineering
Animal Science Electrical Engineering Management Information Systems2 Pharmaceutical Sciences
Ra 7687
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queues Submit Applied Mathematics Electronics and Communications Manufacturing Engineering Pharmacy (4-year program)
Engineering/Electronics Engineering Republic Act No. 7687, also known as the “Science and
Applicant:ofName
Applied Mathematics major in Manufacturing Engineering- Pharmacy major in Clinical Pharmacy Technology Scholarship Act of 1994”, provides for scholar-
ships to talented and deserving students whose families’
Environmental Science Management-Biomedical
Mathematical Finance2 (5-year program) socio-economic status do not exceed the set cut-off values
Engineering3
of certain indicators. Qualifiers must pursue priority fields
Manufacturing Engineering- of study in the basic sciences, engineering, other applied
Applied Physics Fisheries Management-Mechatronics and Physics sciences, and science and mathematics teaching.
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,
Applied Statistics Geodetic Engineering Materials Engineering Chemistry, Physics, Physical Science, The DOST-SEI Merit Scholarship Program, formerly known
Biology and Chemistry) as the NSDB or NSTA Scholarship under RA No. 2067, is
awarded to students with high aptitude in science and
Astronomy Technology Geography Mathematics Statistics mathematics and are willing to pursue careers in the fields
Bachelor of Library and Information Geology Mathematics and Science Teaching of science and technology.
Science
1at UP System only
Bachelor of Secondary Education
early Geothermal Engineering Mathematics Teaching 24 years, ADMU
major in Science 3at DLSU only
on to your Biochemistry Health Science Mechanical Engineering 4BS Program
deadline
Biology Human Biology Mechatronics Engineering
Study Placement
theavoid
longapplication
. daythe
of
the RETURN OF SERVICE CONDITION
State Universities and Colleges (SUC)
Upon completion of the S&T program, the scholar-graduate shall render return service in the country on a full-time basis, CHED identified Centers of Excellence (COE) or Centers of
preferably in his/her home region, and preferably along his/her field of specialization, for a minimum period equivalent to Development (COD) for the S&T programs covered under
the length of time he/she enjoyed the scholarship. the DOST-SEI Undergraduate Scholarships
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:
economic status does not exceed the set values of certain indicators; Logical Reasoning, Science, Mathematics, English, Mechanical-Technical and a Self-Inventory.
Member of the STEM Strand senior high school graduating class; OR
Member of the top five percent (5%) of the Non-STEM Strand senior high E. Selection Criteria
school graduating class; The awardees shall be selected on the basis of their performance in the 2020 S&T Undergraduate Scholarship
Resident of the municipality for the last 4 years as attested by the barangay Examination.
chairman;
Of good moral character and in good health; and F. Final Selection
Qualifier of the 2020 S&T Scholarship Examination The list of awardees as approved and announced by the DOST Secretary is final and unappealable.