TO BE FILLED-OUT BY DOST/SEI STAFF ONLY STSD-101.

1
Republic of the Philippines Rev. 2 / 07-02-19
TCC APPLN. NO. Department of Science and Technology
- SCIENCE EDUCATION INSTITUTE NOT FOR SALE
CAN BE REPRODUCED
2018 Total Annual Family Gross Income: P.O. Box 18 Taguig Post Office ALL ENTRIES/SIGNATURE IN
(Taxable & Non-taxable) ₱ __________________ THIS FORM MUST BE ORIGINAL.

Ave. Electricity Consumption

____________ kwh
for 3 months:
Annual HS Net Tuition & Attach recent
Other School Fees:₱ __________________ 2020 DOST-SEI
Ownership of Vehicle: _______________________
Scholarship Program Assessment:
SCIENCE AND TECHNOLOGY 1” x 1”
RA 7687 UNDERGRADUATE SCHOLARSHIPS photo here
MERITP200.00/O.R. No. _____________
APPLICATION FORM

Once officially stamped,

Assessed by: ____________________________ DO NOT detach photo.
Printed Name / Signature Deadline for Filing of Application: September 6, 2019 Attach another copy
Schedule of Examination: October 20, 2019 of the same 1” x 1” photo
SEI DOST RO. No. ___ for the Test Permit.

FORM A – PERSONAL INFORMATION

Instruction: Write clearly in CAPITAL LETTERS your personal information 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): DepEd Learner Reference Number:

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.

II. FAMILY DATA

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

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:

 RA 7687 SCIENCE AND TECHNOLOGY SCHOLARSHIP

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.

 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.
 FORM B – HOUSEHOLD INFORMATION QUESTIONNAIRE (HIQ)
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 Relationship Age Civil Highest Grade or Year Occupation of Class of Gross Income
(Put Household Head* as first in the list; include to Applicant Status Educational Attending if Working Worker for the Year
name of applicant) (See Attainment Currently in Household (See 2018 (in pesos)
codes (Specify grade, School Member codes
below) year or degree) below)

(1) (2) (3) (4) (5) (6) (7) (8) (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. Total: ________________

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)

II. FINANCIAL CONTRIBUTION

If both parents are unemployed, do you have any sibling/s or relative/s other than those named in the ( I.)Household Profile (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:
____________________

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.

III. OTHER HOUSEHOLD INFORMATION

Electric Consumption for the last Three Months: Does your family share electricity with other families?
Yes No
Month 1: Month 2: Month 3:
kwh kwh kwh 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) Signature of Certified True and Correct:
Name of Family Heads* Month 1Month 2Month 3 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: 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
Does your family own agricultural land or non-residential land? Yes No If yes, what is the lot area in
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

TO WHOM IT MAY CONCERN:

This is to certify that _________________________________________________has consistently maintained good moral character,

(Name of Applicant)
there having no disciplinary action taken against him/her as of the date of application.

_______________________________________________
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.

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)

_________________________________________________
Medical Doctor/School Physician’s Printed Name & Signature
License No.: ______________________________________
Date: ____________________________________________

FORM E1 – PRINCIPAL'S CERTIFICATION (For Applicant from the STEM Strand)

TO WHOM IT MAY CONCERN:

This is to certify that _________________________________________________ is a candidate for the Grade 12 graduation under the
(Name of Applicant)

STEM Strand of the ______________________________________________________________________ for the SY 2019-2020.

(Name of School/Address)

_______________________________________
Printed Name & Signature of Principal
Date: __________________________________

FORM E2 – PRINCIPAL'S CERTIFICATION (For Applicant from the NON-STEM Strand)

TO WHOM IT MAY CONCERN:

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: __________________________________

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 G – PARENT'S CERTIFICATION

This is to certify that my son/daughter, _________________________________________________, has no pending application for

immigration to the USA or any other country. (Name of Applicant)

_______________________________________
Printed Name & Signature of Parent
Date: __________________________________
 FORM H – APPLICANT'S CERTIFICATION

This is to certify that the undersigned has (Check all that apply):

NOT taken any previous DOST-SEI Undergraduate Scholarship 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.

NOT earned any post-secondary or undergraduate units.

Noted by: _____________________________________ _______________________________________

Printed Name & Signature of Parent or Guardian Printed Name & Signature of Applicant
Date: __________________________________ Date: __________________________________

FORM I – SIGNED DECLARATION BY APPLICANT AND THE PARENTS/LEGAL GUARDIAN:

Form A – Personal Information
Form B – Household Information Questionnaire (for RA 7687 Applicants only)
Form C certify
I/We hereby – Certificate
to theof Good Moraland
truthfulness Character
completeness of information provided. Any misinformation or withholding of information will
Formdisqualify
automatically D – Certification
my/our of Good Healthfrom the DOST-SEI Science and Technology Undergraduate Scholarship Program. I/we are also
son/daughter
willing to Form
refundE1all– the
Principal’s
financialCertification (For Applicant
benefits received plus thefrom the STEM
appropriate Strand)if such misinformation is discovered after my/our child accepted
interest
the award. Form E2 – Principal’s Certification (For Applicant from the NON-STEM Strand)
Form F – Certificate of Residency (For RA 7687 Applicants only)
Form G – Parent’s Certification (If no pending application for immigration)
In connection with this application for scholarship, I/we hereby authorize the DOST-SEI designated representative to conduct a
Form H – Applicant’s Certification
background check on the family’s socio-economic status and to visit our family dwelling.
Form I – Signed Declaration by Applicant and the Parent/s/Legal Guardian
Two recent (1" x 1") pictures
Moreover, I/we hereby
Photocopy express
of Birth my/our consent for the Science Education Institute of the Department of Science and Technology
Certificate
(SEI-DOST) to collect,
Parent/s 2018record,
Income organize,
Tax Return update/ W2or/ Employment
modify, retrieve, consult,
Contract use, consolidate,
for OFW / BIR block, erase or destruct my personal data for the
preparations of the publication
Certificate of Exemptionof thefor
list of scholarship
Filing qualifiers
of ITR / Municipal or and as inputs
Barangay for decision making in policy formulation relative to the
Certificate
DOST-SEI scholarship
of Indigency programs. I/We hereby affirm
(for RA 7687Applicants only)my/our right to be informed, object to processing, access and rectify, suspend or withdraw
my/our personal
Electric data, and3 be
Bills for indemnified
consecutive in case
months in of damages
2019 (for RApursuant to the provisions
7687 Applicants only) of the Republic Act No. 10173 of the Philippines, Data
Privacy Act of 2012ofand
Affidavit its corresponding
guardianship Implementing
(If with legal guardian)Rules and Regulations.
Certificate of scholarship in high school (If applicable) THIS APPLICATION FORM AND
Applicant’s
Father’s
High
Signature
School
Signature
Statement of Account (If applicable) Mother’s Signature Legal Guardian’s
ATTACHED
____________________________
Signature
DOCUMENTS WERE
Over Printed
Others:name For DOST SEI/RO Staff use only
______________________________________________________
____________________
________________ Date Signed
Or Over : Checklist
_________________Over
Printed name Printedof
________________ Documents
name Or
Date
DateSubmitted
Remarks:
of
ofVERIFIED
Review
Return
Printed
of
of
_______________Over
FOR
Applicant:
Documents:
Name/Signature
COMPLETENESS
_____________
_____________
Printed
BY: name
 A. General
TCC/ Name2020 ofCriteria
(Detachab of Eligibility INSTRUC RA 7687 MERIT S &T P rograms Cove re dD.Unde Examination
r the DOS Coverage
T -S EI
Applicatio
Applicant:
DOST-SEI
le Label) 1. Make sure you have read
 Natural-born
n No.:__________
Filipino
S&T
citizen;
the attached brochure TIONS:
about   Unde rgra dua
This scholarship te S cholar
examination is designedships
to measure abilities that determine academic and
the DOST-SEI professional
 Poor,__________
talented
__________ and deserving
Undergrad student whoS&T belongs to a family whose
  success in science, technology, engineering, and mathematics. The test includes the following
socio-
_________
__________
uate Undergraduate Scholarship domains:Engineering Medical Laboratory Science/Medical
economic status does not exceed the set values of certain Aeronautical Engineering
indicators; Ceramics Industrial Design
Programs.2. Accomplish the Logical Reasoning, Science, Mathematics, English, Mechanical-Technical Technology and a Self-Inventory.
(to be__________
 Member of Scholarshi
the STEM Strand senior high school graduating class; OR
E. Selection Criteria
Application
(5%) ofForm completely
 Member
filled
high
by
up
DOST)
of the
p top five percent
__________
__________ with the
the Non-STEM
necessary
Strand senior
Aerospace 
Engineering Chemical Engineering
The awardees shall be selected
Industrial Engineering
on the basis of their performance
Metallurgical Engineering
in the
Science and Technology
2020 S&T Undergraduate
school graduating class; signatures.3. Put the Scholarship Industrial Management Engineering-
__________
 Resident of the municipality for the last 4 years as attested by the
accomplished Application
Agribusiness Management
 
Chemistry
Examination. Information Technology3 Meteorology Undergraduate Scholarships
__________
barangay
chairman;
______ Form and all the documentary Agricultural and Biosystems Chemistry with Applied Computer F. Final Selection
 Of good moral character requirements
and in good health;in a long brown Engineering  Industrial Pharmacy Microbiology
Systems
and The list of awardees as approved and announced by the DOST Secretary is final and

Types of
 Qualifier of the 2020 S&Tenvelope.4.
Scholarship Fill-out the   unappealable.
Chemistry with Materials ScienceInformation
and and Communications
Examination detachable label below and Agricultural Biotechnology1 Mining Engineering
B. Scholarship Privileges paste it on the upper left hand
Engineering G. Terms
Technology and Conditions
Tuition and other school fees corner of the long brown Agricultural
P40,000.00Chemistry Civil
per Academic Yeara) AnEngineering
awardee must seek admission Information
in any System
of the S&T programsMolecular Biologythe
covered under & Biotechnology
DOST-SEI
envelope.5. Submit the brown Undergraduate

Scholarships
Book Allowance AgriculturalP10,000.00
Economics per year Community Nutrition
Scholarships Information Technology
in any of the following: Nutrition
envelope with the complete
MS/PE uniform (1st Semester of First Year only) P1,000.00 a.1 State universities and colleges.
requirements to DOST-SEI; or Agricultural Engineering Computer Engineering
a.2 Tertiary Information
institutions identified Technology
as Centers Systems
of Excellence or Nutrition
Centers ofand Dietetics by CHED or
Development
Group Insurance the DOST Regional Office or Premium Level III
Agricultural Technology Computer Science Instrumentation and Control Eng’g. Packaging Engineering
Transportation Allowance (for thethose
Provincial
studying outside of home 1 economy-class roundtrip fare accredited by FAAP for the S&T programs covered under the DOST-SEI Undergraduate
Scholarships.
Science and Technology
Ra 7687
province) Agriculture Doctor of Veterinary
He/She Medicine
should pass Life Sciences
the qualifying examination for admission Petroleum Engineering
to the university where he/she
Monthly Living Allowance P7,000.00 per month a.3 DOST-SEI identified network institutions.
Center nearest you on or plans to enroll in.
Summer Allowance (if required per curriculum) Animal Science Electrical Engineering Management Information Systems Pharmaceutical
2 Sciences
before 6 September 2019. b) An awardee shall comply with the terms of the Scholarship Agreement to be entered into between
 Tuition and other school fees P1,500.00 Electronics and Communications
6. When your application is in Applied Mathematics himself/ Manufacturing Engineering Pharmacy (4-year program) Republic Act No. 7687, also known as the “Science and
 Book Allowance order, you will be issued a Test P500.00 (to submit O.R.)Engineering/Electronics
herself, parents or legalEngineering
guardian and the DOST-SEI. Technology Scholarship Act of 1994”, provides for scholar-
c) After signing the Scholarship Agreement, the awardee’s name shall be included in the lists of ships to talented and deserving students whose families’
 Monthly Allowance Permit and a Primer. 2 monthsscholars Manufacturing Engineering- socio-economic status do not exceed the set cut-off
Applied Mathematics major in Pharmacy major in Clinical Pharmacy
Environmental Management-Biomedical
Sciencefrom DOST-SEI
needing clearance forwarded to the appropriate government agency/ies for values
Graduation clothing allowance Mathematical Finance
P1,000.00
2 (5-year program)
tracking Engineering3 of certain indicators. Qualifiers must pursue priority fields
C. Items to be Submitted purposes.
Manufacturing Engineering-
of study in the basic sciences, engineering, other applied
d) An awardee shall maintain the grade requirements of the scholarship. sciences, and science and mathematics teaching.
 Form A: Personal Information Applied
 Physics  Fisheries Management-Mechatronics
e) Scholarship qualifiers who come and may
from the non-STEM Strand, Physics
avail of the scholarship effective
the First Robotics3
 Form B: Household Information Questionnaire  
Semester of AY 2020-2021 as long as they are admitted in any of the S&T programs covered under
Applied Physics with Applied the Technology H. Securing / Filing Application Psychology4
 Form C: Certificate of Good Moral Character  Food Marine Biology
Computer System 
merit
DOST-SEI Undergraduate Scholarships in a university that meets the study placement
 Form D: Certificate of Good Health    The application form can be obtained at the Science Education Institute, 2nd Level, Science
requirement.
Applied Physics with Materials
 Form E1: Principal’s Certification that applicant belongs to the senior Heritage Bldg.,
Forestry Marine Science Public Health
Science and Engineering
high   DOST Cmpd., General Santos Ave., Bicutan, Taguig City, Metro Manila; DOST Regional Offices;
Provincial The DOST-SEI Merit Scholarship Program, formerly known
school STEM strand Class Science Teaching (Biology,
 Form E2: Principal’s Certification that applicant belongs to the upper Science and Technology Centers (PSTC) or Offices of the Congressmen andPhysics,
Senators. It can Science,
be as the NSDB or NSTA Scholarship under RA No. 2067, is
Applied
 Statistics  Geodetic Engineering Materials Engineering Chemistry, Physical
5% of downloaded
Accomplishedat www.sei.dost.gov.ph.
form can be filed at the Science Education Institute, or and
DOST Regional Office/PSTC awarded to students with high aptitude in science and
Biology Chemistry)
the NON-STEM strand senior high school graduating class nearest mathematics and are willing to pursue careers in the
 Form F: Certificate of Residency   the applicant’s school or homeMathematics
address. fields
Astronomy Technology Geography Statistics
of science and technology.
 Form G: Parent’s Certification  
Bachelor of Library and InformationDeadline for Filing of Application: Date of Examination:
ion
 Form H: Statement of applicant that he/she has not taken any Science Geology Mathematics and Science Teaching
pplicat
previous
your a
DOST-SEI Undergraduate Scholarship Examination and any
g

Bachelor  Education
of Secondary September 6,Mathematics
Geothermal Engineering
2019 TeachingOctober 20, 2019
atUP System only
4years, ADMU
1
2
undergraduate major in Science 3at DLSU only
Submit
units or post secondary course (In case applicant has already
the lon 4BS Program
 Form I: Signed oDeclaration
graduated by Applicant and the Parent/Legal Biochemistry
   The Science
Health Test Permit shall be mailed to the applicant/s
Mechanical or school principal for distribution to the
Engineering
avoid
Guardian
from senior high school) f the applicants. In Study Placement
 Two recentearly
(1”x1”)
t pictures Biology
  Human Biology Mechatronics Engineering
case the test permit is not received within the week before the examination day, the applicant may
inquire
 Photocopy of BirtheCertificate
da y o
 
s on th from the DOST Regional Office / PSTC and check the nearest designated test center a day before
queue
 Parent/s 2018 Income Tax Return / W2 / Employment Contract for RETURN OF the SERVICE CONDITION
Department of Science and Technology
 State Universities and Colleges (SUC)
OFW / e.   examination. SCIENCE EDUCATION INSTITUTE  CHED identified Centers of Excellence (COE) or Centers of
deadlin
BIR Cert. of Exemption from Filing of ITR / Brgy. Cert. of Indigency Upon completion of the S&T program, the scholar-graduate shall render return
1st and 2nd Levels, Science Heritage Bldg.,service in the country on a
 Electric bill for the recent 3 consecutive  full-timebasis, Development (COD) for the S&T programs covered under
months DOST Compound, General Santos Ave., Bicutan, Taguig City the DOST-SEI Undergraduate Scholarships
preferably in his/her home region, and preferably along
Contact nos. his/her
(02) field of
839-0083, specialization,
(02) for a minimum
837-1333, 837-2071 period
loc. 2382
 Non-refundable test fee of P200.00   to
equivalent www.sei.dost.gov.ph  Institutions with FAAP Level III Accreditation
the length of time he/she enjoyed the scholarship.