2006 Dost-sei Application Form

FORM A

NOT FOR SALE CAN BE REPRODUCED.

TO BE FILLED-UP BY DOST/SEI STAFF ONLY

ALL ENTRIES/SIGNATURE

TCC/APPLN. NO. _________

IN THIS FORM MUST BE

2004 Total Annual Gross Income: P Scholarship Program

ORIGINAL.

Republic of the Philippines

Assessed:

RA 7687

Department of Science and Technology

DOST-SEI Merit

Attach recent 1"x 1" photo here

SCIENCE EDUCATION INSTITUTE P.O. Box 1412 Manila

P200.00/P.R. No. ___________________

Once officially stamped, DO NOT detach photo. Missing stamped photo will make this info sheet null and void. Attach also another 1"x1" photo for the Test Permit.

Assessed by: _____________________________

INFORMATION SHEET

Name in Print/Signature Office:

SEI

for the

DOST R.O. No. _____

DOST-SEI SCIENCE AND TECHNOLOGY SCHOLARSHIPS FOR 2006 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 Deadline for Submission: 4 November 2005 (Friday) I. PERSONAL DATA 1. Name of Applicant 2. Sex

Surname Male

Middle Name

First Name

Female

3. Citizenship

4. Date of Birth

5. Place of Birth

6. Permanent Address No.

Street

District

7. Number of Children in the Family

City/Municipality

8. Birth Order of Applicant

Province

Zip Code

(1st child, 2nd child, etc.)

9. Name of High School 10. Type of High School

Regular Public

Science

(To be provided by DOST-SEI)

Private

High School Code

11. Address of High School 12. Fourth Year High School Tuition and Other School Fees Paid

P

(Please attach assessment form/statement of account provided by the school). If under scholarship, indicate name of scholarship and submit certification from school or foundation 13. Have you been issued a passport?

Yes

No

Passport No.

II. FAMILY DATA Father

Mother

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

14. Name 15. Highest Educational Attainment 16. Occupation (pls. specify) 17. Employer Address 18. 2004 Annual Income (in pesos) 19. Tribal Affiliation (if any)

III. SCHOLARSHIP INTENTIONS DATA 20. Check appropriate box for scholarship program applied for: RA 7687 SCIENCE AND TECHNOLOGY SCHOLARSHIP For an applicant who belongs to a family whose socio-economic status does not exceed the set values ofALL the identified indicators as approved by the Advisory Committee on the S&T Scholarships. Applicant must thoroughly accomplish the Household Information Questionnaire (Form B). 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.

21. Have you applied for scholarships other than the DOST-SEI? OWWA

If yes, please identify which scholarship:

Yes

No

CHED

GSIS

Others, specify ___________

22. College/University where you intend to enroll: * You are advised to take the admission test of the college/university where you intend to enroll for SY 2006-2007. 23. Test Center nearest your school: * Please refer to the list of designated test centers in the 2006 S&T Scholarship Announcement. The scholarship examination will be administered on 4 December 2005 (Sunday) at the identified test center in your province. I certify that all answers given above are true and correct to the best of my knowledge. Attested by: _____________________________________

_________________________________

Parent/Legal Guardian

Signature of Applicant

(Please print name and sign above it.)

Date: ____________________________

FORM B HOUSEHOLD INFORMATION QUESTIONNAIRE A. HOUSEHOLD PROFILE 1. Profile of household members (Please include ALL members who live under the same roof and share in common food.)

(Ibilang ang mga kasambahay o mga kamag-anak na kasalukuyang nakatira sa bahay at kasama sa inihahaing pagkain.) Relationship Age Name (Put Household Head as to Household Head first in the list)

(1)

(2)

(3)

Civil Status (See codes below.) (4)

Grade or Highest Year Educational Attainment Attending if (Specify grade, Currently in year or degree) School (6)

(5)

Occupation of working household member

Class of Worker (See codes below)

Gross Income for the Year 2004 (in pesos)

(7)

(8)

(9)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. *Household head is the person who generally provides the chief source of income for the household unit. He/She is the adult person, male or female, who is responsible for the organization and care of the household or who is regarded as such by members of the household.

Codes for Col. 4 (civil status): 1 Single

2 Married

3 Widowed

4 Divorced/Separated

5 Unknown

Codes for Col. 8 (class of worker): 1 Works for private household

5 Employer in own family-operated farm/business

2 Works for private establishment

6 Works with pay on own family-operated farm/business

3 Works for gov't agency/corporation

7 Works without pay on own family-operated farm/business

4 Self-employed without any employee (e.g., sari-sari store owner, dressmaker) 2.a 2004 Total Annual Gross Income (Total of entries in column 9)

P

2.b Do you have any relatives, other than those in the profile of household members (whether here or abroad), who contribute in meeting your household expenses? Yes No If yes, how much is the average monthly contribution?

P

/month

(Note: If employed or has own business, provide clear photocopy of Income Tax Returns (ITR) or W-2 for the year 2004. Bring original copy for validation purposes. If unemployed, submit the BIR Certification of Exemption from Non-Filing of ITR or Municipal Certification of Non-employment, in case there is no BIR office in your municipality.)

HEALTH CERTIFICATE FORM C Health Agency/Hospital: Address:

Date

TO WHOM IT MAY CONCERN: This is to certify that I have examined and found him/her to be physically fit.

Name of Applicant

This certification is issued in connection with his/her application for the 2006 DOST-SEI Undergraduate Science Scholarships. Printed Name & Signature of Medical Officer Official Designation/License No FORM D

CERTIFICATE OF GOOD MORAL CHARACTER

Date TO WHOM IT MAY CONCERN: This is to certify that has consistently maintained good moral character, there having no disciplinary action taken against him/her as of to date NOTE: Failure to maintain good moral character before the award of the scholarship shall cause forfeiture thereof. DOST may require another certification before the signing of the Scholarship Agreement. Printed Name & Signature of Principal/Guidance Counselor FORM E-1 For Applicant from Regular High School Name of High School Address PRINCIPAL'S CERTIFICATION TO WHOM IT MAY CONCERN: This is to certify that is a candidate for graduation for the school year and is classified within the upper five percent of the total _____________________ graduating students. Number Printed Name & Signature of Principal FORM E-2 For Applicant from DOST-SEI Identified/DepEd Recognized Science High School PRINCIPAL'S CERTIFICATION TO WHOM IT MAY CONCERN: This is to certify that is a candidate for graduation of for the SY (Name of School/Address) School Type: PSHS System DepEd Regional Science HS Special Science Classes of the 110 S&T Other DepEd Recognized Science High Schools Oriented High Schools (Attach certification from DepEd that the school has a special science curriculum)

Printed Name & Signature of Principal FORM F (In case applicant has already graduated from high school in the previous year) APPLICANT'S CERTIFICATION TO WHOM IT MAY CONCERN: This is to certify that the undersigned has not taken any previous DOST-SEI Scholarship Examination and has not earned any post-secondary or undergraduate units. Printed Name & Signature of Applicant Attested by: Printed Name & Signature of Parent/Guardian FORM G PARENT'S CERTIFICATION has no pending application This is to certify that my son/daughter, for immigration to the USA or any other country. Printed Name & Signature of Parent (For RA 7687 Scholarship Applicants Only) FORM H CERTIFICATE OF RESIDENCY TO WHOM IT MAY CONCERN: is a bonafide resident of This is to certify that for not less than 4 years. (For minority group, please indicate your tribe, if there is any.____________) Printed Name & Signature of Barangay Official/ Principal

FORM B Household Information Questionnaire (Continuation) 3.a. Electric Consumption for the Last Three Months July 2005

kwh

kwh

August 2005

kwh September 2005

(Note: Provide clear photocopies of the electrical bills. Present original copies for verification.) 4. Type of Toilet Facility Used by the Household (Indicate answer in the box provided) 1 Water-sealed, used exclusively by households

3 Closed pit, e.g. Antipolo

2 Water-sealed, shared with other households

4 Open pit

5 Others (pail system, arinola, etc.)

5. Floor area of the housing unit (area in sq.m) 6. Ownership of the housing unit: (Indicate answer in the box provided) 2 Owned, Amortized 3 Rented 4 Rent free/living w/ relatives 1 Owned, Fully Paid 7. Construction material of the walls of the housing unit: (Indicate answer in the box provided) 1 Concrete

3 Wood (e.g., bamboo, coco lumber)

2 Semi-Concrete

4 Makeshift/Salvaged

5 Others, pls. specify ________

8. Owns residential land area other than where the family resides? 9. Owns agricultural or non-residential land?

None (area in sq m) None (area in sq m) 10. Indicate name(s) of existing health card/insurance (other than Philhealth/Medicare/GSIS/SSS) of family members, if any: 11. Indicate name(s) of existing credit cards of the family members, if any: ____________________________________________________ 12. Does your household own any of the following appliances, facilities and vehicles? No. of Working Units ___________

Appliance/Vehicle Airconditioning unit

Year Acquired (only for the latest unit) ___________

___________ ___________ ___________

Digital Camera Video Camera or Movie Camera Gas/Electric Range w/ Oven

___________ ___________ ___________

___________ ___________ ___________

Microcomputer Car/Van/Pajero/Other Similar Vehicle Jeepney (AUV/Owner Type)

___________ ___________ ___________

___________

Motorcycle

___________

B. CONTACT ADDRESS/NO. (Indicate as many as possible) Mailing Address Applicant

Parent/Legal Guardian

Landline Phone No. Cell Phone No. Fax No. Email Address SIGNED DECLARATION BY 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 child from the DOST-SEI 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 financial aid, I/we hereby authorize the DOST-SEI/DOST Regional Office to conduct a credit check on the family finances, including bank accounts, credit card accounts, SSS and GSIS accounts, and to visit our family dwelling.

Father’s Signature Over Printed Name

Mother’s Signature Over Printed Name

OR Legal Guardian’s Signature Over Printed Name

Date

TO BE FILLED-UP BY DOST/SEI STAFF ONLY THIS APPLICATION FORM AND ACCOMPANYING DOCUMENTS WERE VERIFIED FOR COMPLETENESS BY: Name:

___________________________________________

Remarks: _________________________________________

Signature: ___________________________________________ Office: SEI DOST R.O. No. _____

_________________________________________________ _________________________________________________

Date: _______________________________________________

_________________________________________________