TO BE FILLED-OUT BY DOST/SEI STAFF ONLY Republic of the Philippines STSD-101.

2
TCC APPLN. NO. Rev. 2 / 03-18-19
Department of Science and Technology
- NOT FOR SALE
SCIENCE EDUCATION INSTITUTE CAN BE REPRODUCED
2018 Total Annual Family Gross Income:
(Taxable & Non-taxable) ₱ __________________ P.O. Box 18 Taguig Post Office ALL ENTRIES/SIGNATURE IN
THIS FORM MUST BE ORIGINAL.
Ave. Electricity Consumption
____________ kwh
of 3 months:
General Weighted Average: _________________ Attach recent
Ownership of Vehicle: _______________________
Scholarship Program Assessment: 2019 JUNIOR LEVEL 1” x 1”
MERIT P200.00/O.R. No. ____________ SCIENCE SCHOLARSHIPS photo here
RA 7687
RA 10612
APPLICATION FORM

Once officially stamped,

Assessed by: ____________________________
DO NOT detach photo.
Printed Name / Signature Deadline for Filing of Application: April 26, 2019 Attach another copy
SEI DOST RO. No. ___ Schedule of Examination : June 2, 2019 of the same 1” x 1” photo
for the Test Permit.

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): 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 ____________________
S&T Program Enrolled in: 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
(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: Forms to be filled-out
For an applicant enrolled in science, technology, engineering and mathematics who shall
 RA 10612 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
 RA 7687 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

 MERIT 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 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 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: ____________________

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 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: 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 1 Month 2 Month 3 Family Heads
1.
2.
3.
4. ______________________________________
Printed Name & Signature of Barangay Official
5. 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

(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 Printed Name & Signature of Applicant
Date: ______________________________________ 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 Printed Name & Signature of Applicant
Date: ______________________________________ 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 Printed Name & Signature of Applicant
Date: ______________________________________ 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 _________________ Date Signed _________________

Father’s Signature Mother’s Signature Legal Guardian’s Signature

Or Or
Over Printed name ________________ Over Printed name ________________ 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: ______________________________________________________
 (Detachable Label)
TCC/ Application No.: ____________________________ (to be filled up by DOST)
Name of Applicant: __________________________________________________________________________________
2019 Junior Level Science Scholarships
INSTRUCTIONS:
S&T Programs Covered by the DOST-SEI
6.
5.
4.
3.
2.
1.
Undergraduate Scholarships
When your application is in order, you will be issued a Test Permit and a Primer
nearest you on or before 26 April 2019.
Submit the brown envelope with the complete requirements to DOST-SEI; or the DOST Regional Office or the Provincial Science and Technology Center
Fill-up the detachable label below and paste it on the upper left hand corner of the long brown envelope.
Put the accomplished Application Form and all the documentary requirements in a long brown envelope.
Accomplish the Application Form completely with necessary signatures.
Make sure you have read the attached brochure about the DOST-SEI S&T Undergraduate Scholarship Programs.
Aeronautical Engineering
Aerospace Engineering
Agribusiness Management
Agricultural and Biosystems
Engineering
Agricultural Biotechnology1
Agricultural Chemistry
Agricultural Economics
Agricultural Engineering
Agricultural Technology
Agriculture
Animal Science
Applied Mathematics
Applied Mathematics major
in Mathematical Finance2
Applied Physics
Applied Physics with Applied
Computer System
Applied Physics with
Materials Science and
Engineering
Applied Statistics
Astronomy Technology
Bachelor of Library and
Information Science
Bachelor of Secondary
Education major in Science
Biochemistry
Biology
Ceramics Engineering
Chemical Engineering
Chemistry
Chemistry with Applied
Computer Systems
Chemistry with Materials
Science and Engineering
Civil Engineering
Community Nutrition
Computer Engineering
Computer Science
Doctor of Veterinary Medicine
Electrical Engineering
Electronics and Communications
Engineering/Electronics
Engineering
Environmental Science
Fisheries
Food Technology
Forestry
Geodetic Engineering
Geography
Geology
Geothermal Engineering
Health Science
Human Biology
Industrial Design
Industrial Engineering
Industrial Management
Engineering-Information
Technology3
Industrial Pharmacy
Information and
Communications Technology
Information System
Information Technology
Information Technology Systems
Instrumentation and Control
Engineering
Life Sciences
Management Information
Systems2
Manufacturing Engineering
Manufacturing Engineering-
Management-Biomedical
Engineering3
Manufacturing Engineering-
Management-Mechatronics and
Robotics3
Marine Biology
Marine Science
Materials Engineering
Mathematics
Mathematics and Science
Teaching
Mathematics Teaching
Mechanical Engineering
Mechatronics Engineering
Medical Laboratory
Science/Medical Technology
Metallurgical Engineering
Meteorology
Microbiology
Mining Engineering
Molecular Biology and
Biotechnology
Nutrition
Nutrition and Dietetics
Packaging Engineering
Petroleum Engineering
Pharmaceutical Sciences
Pharmacy
(4-year program)
Pharmacy major in Clinical
Pharmacy
(5-year program)
Physics
Psychology4
Public Health
Science Teaching (Biology,
Chemistry, Physics, Physical
Science, Biology and
Chemistry)
Statistics
1at UP System only
24 yrs, ADMU
3at DLSU only
4BS Program
RETURN SERVICE
2019
CONDITION
Upon completion of the S&T course, the scholar-graduate
shall teach full time high school subject/s, namely:
 Agricultural
 Aquaculture
 Biology Junior Level Science
 Chemistry
Scholarships
 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. Types of
Scholarships
STUDY PLACEMENT
RA 10612
 State Universities and Colleges (SUC)
 Other private universities or colleges that are with
The scholarship program under Republic Act No.
CHED-compliant programs
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
STUDY PLACEMENT mathematics in secondary schools throughout the
country.
 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
RA 7687
S&T programs covered under the DOST-SEI
Undergraduate Scholarships
*refer to https://ched.gov.ph/memorandum-orders/ for the Scholarships under the Republic Act No. 7687 are
recognized universities per identified program awarded to poor, talented and deserving students
**refer to http://paascu.org.ph/?page_id=119 for the who belong to families whose socio-economic
universities with accreditation status do not exceed the set values of certain
indicators.
RETURN SERVICE
CONDITION
Upon completion of the S&T program, the scholar-graduate
MERIT
shall return service in the country on a full-time basis, The DOST-SEI MERIT scholarships are awarded to
preferably in his/her home region, and preferably along students with high aptitude in science and
his/her field of specialization, for a minimum period mathematics and are willing to pursue careers in
equivalent to the length of time he/she enjoyed the the fields of science and technology.
scholarship.
A. General Criteria of Eligibility RA 10612 RA 7687 MERIT
Who may APPLY?
 natural-born Filipino citizen;   
 poor, talented and deserving student who belongs to a family whose socio-economic Applicants in regular second year standing for the second semester of AY 2018-2019
  
status does not exceed the set values of certain indicators; who meets eligibility requirements of the JLSS and the following conditions:
 regular 2nd year college student in an identified S&T program for Second Semester of  Have not taken any previous DOST-SEI examination; or
  
AY 2018-2019  Have taken the DOST-SEI Undergraduate Examination but did not qualify for
 has a general weighted average (GWA) of at least 83% or its equivalent in his/her first the scholarship; or
  
year and the first semester of the second year in college  Qualifier of the DOST-SEI Undergraduate Scholarship but did not avail of the
 resident of the municipality for the last 4 years as attested by the barangay chairman;    award
 of good moral character and in good health; and   
 qualifier of the 2019 JLSS Examination    Who should NOT apply anymore?
B. Scholarship Privileges
 Students whose DOST-SEI Undergraduate Scholarship were terminated
Tuition and other school fees P40,000.00 per Academic Year
Book Allowance P10,000.00 per year
Group Insurance Premium D. Where to Secure / File Application
Transportation Allowance 1 economy-class roundtrip fare  The application form can be obtained at the Science Education Institute, 2nd Level, Science
(for those studying outside of home province) 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
Monthly Living Allowance P7,000.00 per month
Congressmen and Senators. It can be downloaded at the website, www.sei.dost.gov.ph.
Summer Allowance (if required per curriculum)
 Tuition and other school fees P1,500.00  Accomplished form can be filed at the Science Education Institute, or DOST Regional
Office/PSTC nearest the applicant’s school or home address.
 Book Allowance P500.00 (to submit O.R.)
 The test permit shall be mailed to the applicant. In case the test permit is not received within the
 Monthly Allowance P7,000.00 per month for 2 months
week before the examination day, the applicant may inquire from the DOST Regional
Post –graduation clothing allowance P1,000.00 Office/PSTC and check the nearest designated test center a day before the examination
C. Items to be Submitted E. Test Fee
 Form A: Personal Information     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
 Form B: Household Information Questionnaire (For RA 7687 only)   
should be SCIENCE EDUCATION INSTITUTE.
 Form C: Certificate of Good Moral Character   
 SEI can only accept cash, postal money orders, telegraphic transfer, certified cashier’s and
 Form D: Certificate of Good Health    manager’s check. PERSONAL CHECKS ARE NOT ACCEPTABLE.
 Form E: Certification of Program of Study and Year Level
(2nd Year Second Semester in AY 2018-2019) F. Selection Criteria
(Potential qualifiers to the JLSS Scholarship Program will be required to submit a The awardees shall be selected on the basis of their performance in the 2019 Junior Level Science
  
certification of regular Third Year Standing in AY 2019-2020; proper notification will be Scholarship Examination.
sent sometime in July – August 2019. Awarding of the scholarship shall be pending the
submission of this requirement.) G. Final Selection
The list of awardees as approved and announced by the DOST Secretary is final and unappealable.
 Form F: Certificate of Residency (For RA 7687 only)   
 Form G1: Commitment to Return of Service (For RA 7687 and MERIT)   
 Form G2: Commitment to Return of Service (For RA 10612 only)   
Deadline for Filing of Application: Date of Examination:
 Form H: Applicant’s Certification   
April 26, 2019 June 2, 2019
 Form I: Signed Declaration   
 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
 Two recent (1”x1”) pictures   
 Photocopy of Birth Certificate   
 Photocopy of any document containing your DepEd Learner Reference Number
  
(High School Diploma, Form 137, etc.)
 Parent/s 2018 Income Tax Return / W2 / Employment Contract for OFW / BIR Cert. of Department of Science and Technology
   SCIENCE EDUCATION INSTITUTE
Exemption from Filing of ITR / Brgy. Cert. of Indigency (for RA 7687 only)
1st and 2nd Levels, Science Heritage Bldg.,
 Electric bills for the recent 3 consecutive months (for RA 7687 only)    DOST Compound, General Santos Ave., Bicutan, Taguig City
 Non-refundable test fee of P200.00 (for MERIT only)    Contact nos. (02) 839-0083, 837-2071 loc. 2382
a
www.sei.dost.gov.ph