TO BE FILLED-OUT BY DOST/SEI STAFF ONLY TCC APPLN. NO.
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.
2011 Total Annual Family Gross Income: P (Taxable & Non-taxable) Month 1 __________ kwh Average Electricity Month 2 __________ kwh Consumption in kwh: Month 3 __________ kwh Total = __________ / 3 mos. CV = __________ kwh 4th Year Annual HS Net Tuition & Other School Fees: P Scholarship Program Assessment: RA 7687 Merit P 200.00/O.R. No. ____________
INFORMATION SHEET for the
Attach recent 1” x 1” photo here
Assessed by: Printed Name/Signature SEI DOST RO. No.: ____
DOST-SEI SCIENCE AND TECHNOLOGY SCHOLARSHIPS FOR 2013
Once officially stamped, DO NOT detach photo. Attach another copy of the 1" x 1" photo for the Test Permit.
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: 05 October 2012 (Friday) Date of Examination: 18 November 2012 (Sunday) I. PERSONAL DATA 1. Name of Applicant Surname Female 3. Date of Birth 6. Do you have a dual citizenship? Cell Phone No. Barangay City/Municipality Yes First Name 4. Place of Birth No If yes, please specify: Middle Name
2. Sex 5. Citizenship
7. Contact Nos.: Landline Phone No. 9. Permanent Address No. Street
8. Email Address: LONE/1st/2nd/3rd/4th/5th/6th/7th District (encircle) Province Zip Code
10. Number of Children in the Family 12. Name of High School 13. Type of High School 14. Address of High School Regular Public
11. Birth Order of Applicant (1st child, 2nd child, etc.)
High School Code (To be provided by DOST-SEI)
15. Tuition and Other School Fees Paid in a Private High School
(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. 16. Have you been issued a passport? II. FAMILY DATA Yes No Passport No. Legal Guardian
Father 17. Name 18. Highest Educational Attainment 19. Occupation (pls. specify) 20. Name of Employer 21. Employer Address 22. 2011 Annual Gross Income (in pesos) (taxable and non-taxable)
(To be accomplished ONLY by those whose parents are deceased, working abroad, etc; should submit affidavit of guardianship)
23. If self-employed, declare 2011 Annual Gross Income. 24. Tribal Affiliation
If applicable, please submit a certification of membership from the local Office of Muslim Affairs or National Commission on Indigenous People.
III. SCHOLARSHIP INTENTIONS DATA 25. Check appropriate box for scholarship program applied for: RA 7687 SCIENCE AND TECHNOLOGY SCHOLARSHIP For 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 the S&T Scholarships. Applicant must thoroughly accomplish the Family Information Questionnaire (Form B) and submit all required documents. 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.
26. Have you applied for scholarship other than the DOST-SEI? If yes, please identify which scholarship: 27. College/University where you intend to enroll: OWWA
No GSIS Others, specify ____________
*You are advised to take the admission test of the college/university where you intend to enroll for SY 2013-2014. 28. Test Center nearest your school: *Please refer to the list of designated test centers in the 2013 S&T Scholarship Announcement. The scholarship examination...
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