Consent For Publication Form

Republic of the Philippines Department of Science and Technology PHILIPPINE SCIENCE HIGH SCHOOL MAIN CAMPUS Agham Road, Diliman, Q.C. 1104

CONSENT FOR PUBLICATION OF RESEARCH PAPER I, ____________________________________________ (complete name of student), of Class 2009 of the Philippine Science High School – Main Campus consent

do not give consent

to the publication of my / our research paper entitled: _____________________________________________________________________ _____________________________________________________________________ (Title of Research Paper) I further

agree

do not agree

to assign the royalties / any amount paid by the publisher to the PSHS-Main Campus to fund the school’s priority research projects. Signature of Student: __________________________ Section: _____ Group # ___ Signed in Quezon City, on ________________, 2009

We, the parents/ guardian, agree

_________________________________ Signature of Guardian/Father over Printed Name

do not agree

______________________________ Signature of Mother over Printed Name

NOTE: Your responses on this form will NOT in any way affect your grade in STR2.