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THE 37th SHIP FOR SOUTHEAST ASIAN YOUTH PROGRAM (SSEAYP)

2010 APPLICATION FORM FOR PARTICIPATING YOUTH (PY)

REGION TO BE REPRESENTED: National Capital Region

Surname: Banta Gender: [ M ]

First Name: Rigoberto Height: 169.6cm Passport-sized photo

Middle Name: Dator Weight: 80 kgs. Age: 17 yrs. old

Nickname: RJ/Jay Birthdate: May 24, 1992 Birthplace: Manila

Official Mailing Address: 259 C-13 Genito Apartments, Tandang Sora, Quezon City (1116)

Residence Address: 259 C-13 Genito Apartments Tandang Sora, Quezon City

Passport No.: _______ Date of Expiry: _______ Tel. No. (landline/Area Code): _____

Email Address: _______________________ Cellphone No.: _________________ _______________________


Pls. Indicate date taken
Religion: ________________ Present Occupation/Position: ____________________

Name of Office or school: ____________ Office or School Address:_______________

Years in the Present Work: ______________ Civil Status: _____________________

Father’s Name: Place of Birth: Occupation:


Mother’s Name: Place of Birth: Occupation:
No. of Brother/s
No. of Sisterr/s
Educational Background Name of School/University Course / Inclusive Dates Honors Received
Elementary University of the Philippines
Integrated School
Secondary University of the Philippines
Integrated School
Tertiary Chonnam National University
Vocational Yonsei University-Korean
Language Institute
Post Graduate
Scholarship Grants Donor Inclusive Dates Honors Received

Youth Organization/Youth Serving Organization Affiliations:


Name of Organization Position Years of Membership Accomplishments

Special Skills or Talents:

Food Restrictions: Allergies

Dialect(s) or Foreign Language(s) Spoken: Filipino, English, Korean


Title of Seminar/Training Course Attended Inclusive Dates No. of Hours Conducted by

Previous Work Experience

Name of Company Position Inclusive Dates Salary

Character References: [not related to you within the third degree of consanguinity]

Name Occupation Address and Telephone No.

Please fill up forms legibly Not for Sale – May be reproduced

Important: Please call or text the SSEAYP Secretariat from May 1, 2010 to get your schedule for the regional interview. Please indicate
your whole name and the region you are representing. [SSEAYP Secretariat Tel. Nos. 781-2386;781-2372 or 743-9399;
Cell # (0920-9181297)]
All facts and data given in this information sheet will be treated with utmost confidentiality
Please name any SSEAYP Alumni you know Relationship

Have you previously applied for SSEAYP?  No  Yes How many times?
How did you know about the program? Have you been a participant of any NYC International Exchange
Newspaper: _____ Radio: ______ Program? [ ] No [ ] Yes

Magazine: _____ TV Ads: ______


If yes, please indicate the Program, year and source of fund
NYC Personnel: ________________________________
(Name of NYC personnel)
Others [pls. Indicate]: ____________________________
Have you rendered voluntary service for the NYC? ? [ ] No [ ] Yes If yes, please state nature of service and how long

Have you been involved with any NYC local program or activity? [ ] No [ ] Yes If yes, please indicate the program(s) and year.

If no, are you willing to enter into a MOA with NYC to render voluntary work for its programs and activities?
Have you joined or attended any SSEAYP activities? [ ] No [ ] Yes If yes, please indicate

Have you availed of any program or scholarship grant offered by the Japanese government? [ ] No [ ] Yes If yes, please indicate the program and year

Have you attended any seminar, conference or trainings abroad? [ ] No [ ] Yes If yes, please indicate the program and year

Do you anticipate to take part in any program, conference, board/bar exams or scholarships this year? [ ] No [ ] Yes If yes, please indicate details

Are you on a scholarship granted by the Department of Science and Technology (DOST) and/or any other government agencies? [ ] No [ ] Yes
If yes, please indicate

Have you ever been convicted of any crime involving moral turpitude? [ ] No [ ] Yes If yes, please indicate the nature and status

Do you have any pending civil and administrative case? [ ] No [ ] Yes f yes, please indicate the nature and status (you will be required to present clearance).

Do you have any physical disability? [ ] Yes, please specify _____________________________ [ ] No

SWORN STATEMENT

I hereby certify upon my honor that all facts and information indicated herein are true and correct to the best of my knowledge. I further declare that any
information given by me that is untrue may constitute a ground for expulsion in the SSEAYP and prosecution for perjury.

Further, I subscribe and agree that the National Youth Commission has the sole prerogative to select, reclassify and nominate the delegates to the Ship for
Southeast Asian Youth Program [SSEAYP], and its decision is final and executory. And if chosen, I will join the activities of the program such as Pre-
departure training (July 17-28), pre-departure activities (Sept. 25-Oct. 24), cruise (Oct. 25-Dec. 16) and post-program evaluation (Dec. 16-18).

IN WITNESS hereof, I am executing and signing this statement voluntarily without compulsion.
_____________________________
Signature

Date Accomplished: ____________________ _____________________________


Res. Cert. Number: ____________________ Notary Public
Date and Place Issued: _________________
Qualifications:
1. Filipino citizen, single, must be between 18-30 years old as of April 1, 9. Preferably a first-time international traveler and or must not have
2010. been a grantee or recipient of any NYC funded international travel or
2. Of good moral character Japanese Government grant;
3. if not employed or not studying, must be residing in the region to be 10. Strong background of Philippine history, geography and culture and
represented for at least two (2) years immediately preceding from the date of the arts;
application; 11. Knowledgeable of the current issues of the Philippines, Japan and
4. If employed, the applicant must be working in the region to be ASEAN countries;
represented for at least two (2) years immediately preceding from the date of 12. Must have served the youth sector as an active officer or member of
application; a youth or youth serving organization for at least two (2) years
5. If a student, the applicant must be studying in the region to be immediately preceding from the date of application;
represented for at least two (2) years immediately preceding from the date of
13. Must be willing to be an NYC volunteer after the program; and
application;
14. Must be willing to take a leave of absence from school or work and
6. if at the time of application, the applicant has less than two (2) years of complete all trainings and activities before, during and after the program:
stay in the workplace, school or residence, the Paper Screening Committee
Pre-departure Training July 17-28, 2010
reserves the right to determine the applicant’s regional representation;
Pre-departure Activities Sept. 25 – Oct. 24, 2010
7. If a student wishes to apply to represent a particular region, he/she must Cruise Oct. 25 – Dec. 16, 2010
present a certification duly signed by the head of the organization or organizer Post-Program Evaluation Dec. 16-18, 2010
that the applicant is actively participating in the region’s activities for at least
two (2) years immediately preceding from the date of application;
8. Physically and mentally fit to travel;
Requirements: [ Please submit only the required documents]
1. 8 copies of Application letter (all original); 5. 8 copies of the Certificate of residency issued by the Punong
Barangay where the applicant is at present residing (1 original and 7
2. 8 copies of notarized application forms with passport sized pictures
photocopies);
with white background attached to each form (all original, no scanned
pictures); 6. 8 copies of Police Clearance or NBI Clearance (1 original and 7
photocopies); and
3. 8 copies of resume (maximum of 3 pages only per set, no other
attachments); 7. 2 self-addressed mailing envelopes with stamp worth P20.00 each
envelope (mailing address must be the official mailing address stated in
4. 8 copies of Certificate of Good Moral Character issued by either
the application form)
school, community, non-government organization or institution in the
region to be represented (1 original and 7 photocopies); Passport must be valid until April 25, 2011
NYC AREA OFFICES
LUZON VISAYAS MINDANAO
Room 15, Forest Inn 3/F Monzon Building Myra’s Pension House 2/F Climbs Building Room 308 Jose Go Huilo
Legarda Road, Baguio City Elias Angeles cor. Arana Escario St., Cebu City Tianno, Pacana Tomas Claudio Ext.
Tel. No. 074-6190511 Naga City Tel. No. 032-2341500 Cagayan de Oro City Zamboanga City
Mr. Armando Angeles Jr. Tel. No. 054-8115804 Ms Rhenelyn Dadulo Tel. No. 088-8575895 Tel. No. 062-9924851
Ms. Nydia Paladan Mr. Eddie Cuaresma Mr. Raymond Domingo

NOTE:
 Non-extendible deadline for submission of application form is 5:00 o’clock pm on April 16, 2010.
 The National Youth Commission reserves the right and prerogative to exclude applicants who will not meet the minimum requirements of the Program.
Lack or non-compliance of any of the above stated requirements will mean automatic disqualification without notice.
 Mail or hand carry your application to Ms. Marielou A. Chua, National Youth Commission, 4th Flr., Bookman Building, 373 Quezon Avenue, Quezon
City, Tel Nos. 781-1617/781-1152/781-1406/749-9401/749-9404/749-9409/749-9399 locals 113 and 115.
Please fill up the forms legibly [pls. Photocopy and submit 8 copies]

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