2019jlssappbrochure.pdf

TO BE FILLED-OUT BY DOST/SEI STAFF ONLY TCC APPLN. NO. 2018 Total Annual Family Gross Income: (Taxable & Non-taxable) ₱ __________________ Ave. Electricity Consumption ____________ kwh of 3 months: General Weighted Average: _________________ Ownership of Vehicle: _______________________ Scholarship Program Assessment: MERIT P200.00/O.R. No. ____________ RA 7687 RA 10612

Assessed by:

STSD-101.2 Rev. 2 / 03-18-19

Republic of the Philippines Department of Science and Technology SCIENCE EDUCATION INSTITUTE P.O. Box 18 Taguig Post Office

NOT FOR SALE CAN BE REPRODUCED ALL ENTRIES/SIGNATURE IN THIS FORM MUST BE ORIGINAL.

Attach recent 1” x 1”

2019 JUNIOR LEVEL SCIENCE SCHOLARSHIPS APPLICATION FORM

photo here

Once officially stamped, DO NOT detach photo. Attach another copy of the same 1” x 1” photo for the Test Permit.

____________________________ Printed Name / Signature SEI

DOST RO. No. ___

Deadline for Filing of Application: Schedule of Examination :

April 26, 2019 June 2, 2019

FORM A – PERSONAL INFORMATION 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.

I. PERSONAL DATA Name of Applicant (Last Name, First Name, Middle Name, Suffix Name):

Date of Birth (MM/DD/YYYY):

/

Number of Children in the Family:

Birth Order of Applicant (1st child, 2nd child, etc.):

Mobile Phone No.:

Email address:

Citizenship:

/

Sex:

Male

Place of Birth:

Female

Permanent Address (House/Unit No., Street, Lot/Blk, VIllage/Barangay):

City/Municipality:

Province:

Zipcode:

District:

S&T Program Enrolled in:

Do you have dual citizenship?

If yes, please specify:

Yes

____________________

No

Have you been issued a passport?

If yes, write the Passport No.:

Yes

____________________

No

DepEd Learner Reference Number:

Name of University/College: (Please spell-out the name and indicate campus, if applicable)

Address of University/College:

II. FAMILY DATA Legal Guardian Father

(To be accomplished ONLY by those whose parents are deceased, working abroad, etc; should submit affidavit of guardianship)

Mother

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:

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RA 10612

  MERIT

RA 7687

Forms to be filled-out

For an applicant enrolled in science, technology, engineering and mathematics who shall teach science, mathematics and technology in any of the secondary schools throughout the country.

Form A, C, D, E, G2, H, and I

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.

Form A, B, C, D, E, F, G1, H, and I

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 A, C, D, E, G1, H, and I

FORM B – HOUSEHOLD INFORMATION QUESTIONNAIRE (HIQ) (For RA 7687 Applicants only) 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 (Put Household Head* as first in the list; include name of applicant)

Relationship Age to Applicant

(1)

(2)

Civil Status

Highest Educational Attainment

(See codes below)

(Specify grade, year or degree)

(4)

(5)

(3)

Grade or Year Attending if Currently in School

Occupation of Working Household Member

Class of Worker

(6)

(7)

(8)

(See codes below)

Gross Income for the Year 2018 (in pesos)

(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. Codes for Column 4 (civil status): S – Single M – Married W – Widowed D – Divorced/Separated U – Unknown

Codes for Column 8 (class of worker): A – Works for private household B – Works for private establishment C – Works for government agency/corporation D – Self-employed without any employee (e.g., sari-sari store owner, dressmaker)

Total: ________________

E – Employer in own family-operated farm/business F – Works with pay on own family-operated farm/business G – Works without pay on own family-operated farm/business H – Unemployed (e.g. housewife)

II. FINANCIAL CONTRIBUTION If both parents are unemployed, do you have any relative/s other than those in the profile of household members (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 Annual Household Gross Income in 2018 (I. Household Profile + II. Financial Contribution)

Total:

____________________

₱______________________

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 lalagpas sa ₱250,000.00, magpasa ng kopya ng BIR Certification of Exemption ng pag file ng ITR.  Kung ang kumikita sa pamilya ay walang employer at ang taunang kita ay hindi lalagpas sa ₱250,000.00, 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: Month 1:

Does your family share electricity with other families?

Month 2:

Yes

Month 3:

kwh

kwh

kwh

No

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) Month 1 Month 2 Month 3

Name of Family Heads*

Signature of Family Heads

1. 2. 3. 4. 5.

______________________________________ Printed Name & Signature of Barangay Official Date: _________________________________

*indicate in the first number the name of applicant’s parent.

Ownership of the housing unit:

Owned, Fully Paid Owned, Amortized

Rented Rent free/living with relatives

Others, pls. specify

Does your family own agricultural land or non-residential land? Yes Does your family own vehicle/s? Yes

Certified True and Correct:

No

If rented, how much is the If amortized, how much is the monthly rental? monthly amortization?

If yes, what is the lot area in square meters? ___________________ sq. m.

No

Type Tricycle Passenger vehicle (e.g. Jeepney, Van, etc.) Car/AUV/SUV Truck/Bus

No. of working units

Year Model (ex. 2000, 2008)

Make (ex. Honda, Suzuki, Toyota)

FORM C – CERTIFICATE OF GOOD MORAL CHARACTER TO WHOM IT MAY CONCERN: This is to certify that __________________________________________________________________ has consistently maintained (Name of Applicant)

good moral character, there having no disciplinary action taken against him/her as of the date of application.

_______________________________________________ Printed Name & Signature of Dean of Student Affairs 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)

_______________________________________________ Doctor’s Printed Name & Signature License No.: ____________________________________ Date: __________________________________________

FORM E – CERTIFICATION OF PROGRAM OF STUDY AND YEAR LEVEL TO WHOM IT MAY CONCERN: This is to certify that ________________________________________________________________________________ is enrolled in (Name of Applicant)

Bachelor of Science in _______________________________________________________________ as a REGULAR SECOND YEAR student (Program of Study)

for Second Semester AY _____2018-2019____ at the ________________________________________________________________. (College/University)

_______________________________________________ Printed Name & Signature of College Dean Date: __________________________________________ NOTE: Potential qualifiers to the JLSS Scholarship Program will be required to submit a certification of Regular Third Year Standing in AY 2019-2020; proper notification will be sent sometime in July – August 2019. Awarding of the scholarship shall be pending the submission of this requirement.

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 G1 – COMMITMENT TO RETURN OF SERVICE (For RA 7687 and MERIT Applicants only) This is to certify that the undersigned AGREES to render service in the country preferably along the field of specialization, on a full-time basis for a minimum period equivalent to the duration of the scholarship.

Noted by:

_____________________________________

_____________________________________

Printed Name & Signature of Parent Date: ______________________________________

Printed Name & Signature of Applicant Date: _________________________________________

FORM G2 – COMMITMENT TO RETURN OF SERVICE (For RA 10612 Applicants only) This is to certify that the undersigned AGREES to teach in the secondary level of basic education in a public or private high school in the Philippines soon after graduation as return service. In case of failure to comply with the terms of the Service Agreement, the undersigned agrees to repay the amount disbursed for his/her scholarship, plus applicable interest.

Noted by:

_____________________________________

_____________________________________

Printed Name & Signature of Parent Date: ______________________________________

Printed Name & Signature of Applicant Date: _________________________________________

FORM H – APPLICANT’S CERTIFICATION This is to certify that the undersigned has: NOT taken any previous DOST-SEI 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.

Noted by:

_____________________________________

_____________________________________

Printed Name & Signature of Parent Date: ______________________________________

Printed Name & Signature of Applicant 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 Junior Level Science 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 as part of my/our information. 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

Father’s Signature Over Printed name ________________

Or

Date Signed _________________

Mother’s Signature Over Printed name

________________

Or

Legal Guardian’s Signature _______________ 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 E – Certification of Program of Study and Year Level Form F – Certificate of Residency (for RA 7687Applicants only) Form G1 – Commitment to Return of Service (for RA 7687 and MERIT Applicants only) ____________________________ Form G2 – Commitment to Return of Service (for RA 10612 Applicants only) Printed Name/Signature Form H – Applicant’s Certification Form I – Signed Declaration by Applicant and the Parent/Legal Guardian Official Transcript of Records (TOR) or Certified True Copy of Grades (TCG) Two recent (1" x 1") pictures Date of Review of Documents: _____________ Photocopy of Birth Certificate Photocopy of any document containing the DepEd Learner Reference Number 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 the recent 3 consecutive months (for RA 7687 Applicants only) Remarks: Affidavit of guardianship (If with legal guardian) Others: ______________________________________________________

Make sure you have read the attached brochure about the DOST-SEI S&T Undergraduate Scholarship Programs. Accomplish the Application Form completely with necessary signatures. Put the accomplished Application Form and all the documentary requirements in a long brown envelope. Fill-up the detachable label below and paste it on the upper left hand corner of the long brown envelope. Submit the brown envelope with the complete requirements to DOST-SEI; or the DOST Regional Office or the Provincial Science and Technology Center nearest you on or before 26 April 2019. When your application is in order, you will be issued a Test Permit and a Primer

INSTRUCTIONS:

1. 2. 3. 4. 5.

6.

(Detachable Label)

2019 Junior Level Science Scholarships

Name of Applicant: __________________________________________________________________________________

TCC/ Application No.: ____________________________ (to be filled up by DOST)

RETURN SERVICE CONDITION

S&T Programs Covered by the DOST-SEI Undergraduate Scholarships Aeronautical Engineering

Computer Engineering

Marine Biology

Aerospace Engineering

Computer Science

Marine Science

Agribusiness Management

Doctor of Veterinary Medicine

Materials Engineering

Agricultural and Biosystems Engineering

Electrical Engineering

Mathematics

Agricultural Biotechnology1

Electronics and Communications Engineering/Electronics Engineering

Mathematics and Science Teaching

Agricultural Chemistry

Environmental Science

Mathematics Teaching

Agricultural Economics

Fisheries

Mechanical Engineering

Agricultural Engineering

Food Technology

Mechatronics Engineering

Agricultural Technology

Forestry

Medical Laboratory Science/Medical Technology

Agriculture

Geodetic Engineering

Metallurgical Engineering

Animal Science

Geography

Meteorology

Applied Mathematics

Geology

Microbiology

Applied Mathematics major in Mathematical Finance2

Geothermal Engineering

Mining Engineering

Applied Physics

Health Science

Molecular Biology and Biotechnology

Applied Physics with Applied Computer System Applied Physics with Materials Science and Engineering

Human Biology

Industrial Design

Nutrition and Dietetics

Applied Statistics

Industrial Engineering

Packaging Engineering

Astronomy Technology

Industrial Management Engineering-Information Technology3

Petroleum Engineering

Industrial Pharmacy

Pharmaceutical Sciences

Information and Communications Technology

Bachelor of Library and Information Science Bachelor of Secondary Education major in Science

Nutrition

Biochemistry

Information System

Biology

Information Technology

Pharmacy (4-year program) Pharmacy major in Clinical Pharmacy (5-year program) Physics

Ceramics Engineering

Information Technology Systems

Psychology4

Chemical Engineering

Instrumentation and Control Engineering

Public Health

Chemistry

Life Sciences

Science Teaching (Biology, Chemistry, Physics, Physical Science, Biology and Chemistry)

Chemistry with Applied Computer Systems Chemistry with Materials Science and Engineering

Management Information Systems2

Statistics

Civil Engineering

Community Nutrition

Manufacturing Engineering Manufacturing EngineeringManagement-Biomedical Engineering3 Manufacturing EngineeringManagement-Mechatronics and Robotics3

1at

UP System only 24 yrs, ADMU 3at DLSU only 4BS Program

Upon completion of the S&T course, the scholar-graduate shall teach full time high school subject/s, namely:  Agricultural  Aquaculture  Biology  Chemistry  Fisheries Technology  Information Technology  Mathematics  Physics In any school, public or private, within the country, with first priority in his/her home province for a minimum period of two (2) years.

2019 Junior Level Science

Scholarships Types of Scholarships

STUDY PLACEMENT  

State Universities and Colleges (SUC) Other private universities or colleges that are with CHED-compliant programs

STUDY PLACEMENT  State Universities and Colleges (SUC)  CHED identified Centers of Excellence (COE) or Centers of Development (COD)* on the S&T programs covered under the DOST-SEI Undergraduate Scholarships  Institutions with FAAP Level III Accreditation** on the S&T programs covered under the DOST-SEI Undergraduate Scholarships *refer to https://ched.gov.ph/memorandum-orders/ for the recognized universities per identified program **refer to http://paascu.org.ph/?page_id=119 for the universities with accreditation

RETURN SERVICE CONDITION Upon completion of the S&T program, the scholar-graduate shall return service in the country on a full-time basis, preferably in his/her home region, and preferably along his/her field of specialization, for a minimum period equivalent to the length of time he/she enjoyed the scholarship.

RA 10612 The scholarship program under Republic Act No. 10612 aims to strengthen the country’s science and technology education by fast-tracking graduates in the sciences, mathematics and engineering who shall teach science and mathematics in secondary schools throughout the country.

RA 7687 Scholarships under the Republic Act No. 7687 are awarded to poor, talented and deserving students who belong to families whose socio-economic status do not exceed the set values of certain indicators.

MERIT The DOST-SEI MERIT scholarships are awarded to students with high aptitude in science and mathematics and are willing to pursue careers in the fields of science and technology.

A. General Criteria of Eligibility  natural-born Filipino citizen;  poor, talented and deserving student who belongs to a family whose socio-economic status does not exceed the set values of certain indicators;  regular 2nd year college student in an identified S&T program for Second Semester of AY 2018-2019  has a general weighted average (GWA) of at least 83% or its equivalent in his/her first year and the first semester of the second year in college  resident of the municipality for the last 4 years as attested by the barangay chairman;  of good moral character and in good health; and  qualifier of the 2019 JLSS Examination B. Scholarship Privileges

RA 10612

RA 7687

MERIT

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Tuition and other school fees Group Insurance Transportation Allowance (for those studying outside of home province) Monthly Living Allowance Summer Allowance (if required per curriculum)  Tuition and other school fees  Book Allowance  Monthly Allowance Post –graduation clothing allowance C. Items to be Submitted

a

P7,000.00 per month

Students whose DOST-SEI Undergraduate Scholarship were terminated

 Accomplished form can be filed at the Science Education Institute, or DOST Regional Office/PSTC nearest the applicant’s school or home address.

P1,500.00 P500.00 (to submit O.R.) P7,000.00 per month for 2 months P1,000.00

 The test permit shall be mailed to the applicant. In case the test permit is not received within the week before the examination day, the applicant may inquire from the DOST Regional Office/PSTC and check the nearest designated test center a day before the examination

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 Form B: Household Information Questionnaire (For RA 7687 only)  Form C: Certificate of Good Moral Character  Form D: Certificate of Good Health

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 Form F: Certificate of Residency (For RA 7687 only)

Who should NOT apply anymore?

D. Where to Secure / File Application  The application form can be obtained at the Science Education Institute, 2nd Level, Science Heritage Bldg., 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 downloaded at the website, www.sei.dost.gov.ph.

Premium 1 economy-class roundtrip fare

 Form A: Personal Information

 Form E: Certification of Program of Study and Year Level (2nd Year Second Semester in AY 2018-2019) (Potential qualifiers to the JLSS Scholarship Program will be required to submit a certification of regular Third Year Standing in AY 2019-2020; proper notification will be sent sometime in July – August 2019. Awarding of the scholarship shall be pending the submission of this requirement.)

Applicants in regular second year standing for the second semester of AY 2018-2019 who meets eligibility requirements of the JLSS and the following conditions:  Have not taken any previous DOST-SEI examination; or  Have taken the DOST-SEI Undergraduate Examination but did not qualify for the scholarship; or  Qualifier of the DOST-SEI Undergraduate Scholarship but did not avail of the award

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P40,000.00 per Academic Year P10,000.00 per year

Book Allowance

Who may APPLY?

E. Test Fee  For Merit applicants, a non-refundable test fee of P200.00 will be collected. They should send postal money order instead of cash when mailing applications. The payee of the money order should be SCIENCE EDUCATION INSTITUTE.  SEI can only accept cash, postal money orders, telegraphic transfer, certified cashier’s and manager’s check. PERSONAL CHECKS ARE NOT ACCEPTABLE. F. Selection Criteria The awardees shall be selected on the basis of their performance in the 2019 Junior Level Science Scholarship Examination. G. Final Selection

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 Form G1: Commitment to Return of Service (For RA 7687 and MERIT)

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 Form G2: Commitment to Return of Service (For RA 10612 only)

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 Form H: Applicant’s Certification

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 Form I: Signed Declaration

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 Official Transcript of Records (TOR) or True Copy of Grades (TCG) for the first year and the first semester of the second year in college

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 Two recent (1”x1”) pictures

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 Photocopy of Birth Certificate

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 Photocopy of any document containing your DepEd Learner Reference Number (High School Diploma, Form 137, etc.)

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 Parent/s 2018 Income Tax Return / W2 / Employment Contract for OFW / BIR Cert. of Exemption from Filing of ITR / Brgy. Cert. of Indigency (for RA 7687 only)

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 Electric bills for the recent 3 consecutive months (for RA 7687 only)

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 Non-refundable test fee of P200.00 (for MERIT only)

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The list of awardees as approved and announced by the DOST Secretary is final and unappealable.

Deadline for Filing of Application:

April 26, 2019

Date of Examination:

June 2, 2019

Department of Science and Technology SCIENCE EDUCATION INSTITUTE 1st and 2nd Levels, Science Heritage Bldg., DOST Compound, General Santos Ave., Bicutan, Taguig City Contact nos. (02) 839-0083, 837-2071 loc. 2382 www.sei.dost.gov.ph