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

1
Rev. 2 / 07-02-19
TCC APPLN. NO Application ID: Department of Science and Technology NOT FOR SALE

- OPGQXLMY SCIENCE EDUCATION INSTITUTE CAN BE REPRODUCED

ALL ENTRIES/SIGNATURE IN
2018 Total Annual Family Gross Income:
P.O. Box 18 Taguig Post Office THIS FORM MUST BE ORIGINAL.
(Taxable & Non-taxable) ₱ ___________________
Avg. Electricity Consumption
for 3 months: ________________ kwh

Annual HS Net Tuition &

2020 DOST-SEI Attach recent
Other School Fees: ₱__________________ SCIENCE AND TECHNOLOGY 1” x 1”
Ownership of vehicle: ___________________________ UNDERGRADUATE SCHOLARSHIPS photo here
Scholarship Program Assessment:
APPLICATION FORM
RA 7687

MERIT P200.00/O.R. No. ____________

Once officially stamped,
Assessed by: _______________________________ DO NOT detach photo.
Printed Name/Signature Attach another copy
Deadline for Filing of Application: September 6, 2019 of the same 1” x 1” photo
SEI DOST RO. No.: _________
Schedule of Examination : October 20, 2019 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): DepEd Learner Reference Number:
BARUC, YVONNE CAROL, SUMA-OY
1 0 7 0 1 8 0 6 0 0 1 5
Number of Children in the
Date of Birth (MM/DD/YYYY): Place of Birth: Birth Order of Applicant (1st child, 2nd child, etc.):
Family:
04/04/2001 TONDO, MANILA 3 1st
Sex: Mobile Phone No.: Email address: Citizenship:
Male ✔ Female 09164876544 [email protected] Filipino
Permanent Address (House/Unit No., Street, Lot/Blk, VIllage/Barangay): Do you have dual If yes, please specify:
0533 MASINIT, PUROK 3 SAN ISIDRO citizenship?
Yes ✔ No
City/Municipality: Province: Zipcode: District: Have you been issued a If yes, write the Passport No.:
SUBIC ZAMBALES 2209 1 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

ST. JAMES SCH., INC. ₱ 24650.00

Address of School: *Please attach Assessment Form or Statement of Account provided by the school. If with
scholarship or a voucher recipient, also submit a certification from school or foundation
ASINAN POBLACION, SUBIC, ZAMBALES indicating the name of scholarship and amount of grant.

II. FAMILY DATA

Legal Guardian
(To be accomplished ONLY by those whose
Father Mother parents are deceased, working
abroad, etc; should submit affidavit of
guardianship)
Name Loreto E. Baruc Susan S. Baruc
Contact Number 09501038941 09187548297
Highest Educational Attainment First Year College Second Year College
Occupation (pls. specify) Self-employed Salesclerk
Name of Employer Loreto E. Baruc Susan S. Baruc
Employer Address San Isidro, Subic, Zambales San Isidro, Subic, Zambales
2018 Annual Gross Income 15000 21000
(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 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)(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 Occupation of Class of Gross
(Put Household Head* as first in the list; to Applicant Status Educational Year Working Worker Income for
include name of applicant) (See Attainment Attending if Household (See codes the Year
codes (Specify grade, Currently in Member below) 2018
below) year or degree) School (in pesos)
(1) (2) (3) (4) (5) (6) (7) (8) (9)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
*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/busines
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
Relationship of Contributor to
Purpose of Financial Contribution Frequency of Contribution Annual Contribution
Applicant
(e.g., educational assistance) (see codes below) (In pesos)
(e.g., brother who is an OFW)

Codes for Column 3 (Frequency of Contribution): A – Monthly B – Quarterly C – Semi Annual D – Annual E – Irregular Total: 0

Total Annual Household Gross Income in 2018 (I. Household Profile + II. Financial Contribution) ₱0
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 1 Month 2 Month 3 Family Heads

___________________________________________
*indicate in the first row the name of applicant's parent Printed Name & Signature of Barangay Official
Date: ____________________________________
Ownership of the housing unit: If rented, how much is the monthly If amortized, how much is the monthly
Owned, Fully Paid Rented Others, pls. specify rental? amortization?
Owned, Amortized Rent free/living with relatives
If yes, what is the lot area in
Does your family own hectare/s of agricultural land or non-residential land? Yes No
square meter? __________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 YVONNE CAROL SUMA-OY BARUC 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 Principal/Guidance Councelor

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 YVONNE CAROL SUMA-OY BARUC 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 to certify that YVONNE CAROL SUMA-OY BARUC is a candidate for the Grade 12 graduation under the
(Name of Applicant)
STEM Strand of the ST. JAMES SCH., INC. / Asinan Poblacion, Subic, Zambales 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 Printed Name & Signature of Principal
grade 11 (i.e., top 5% of his/her class) 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:

✔ 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.
NOT earned any post-secondary or undergraduate units.

Noted by: ____________________________________________________ YVONNE CAROL SUMA-OY BARUC

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 Science and Technology Undergraduate 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 for the
preparations of the publication of the list of scholarship qualifiers and as inputs for decision making in policy formulation relative to the DOST-SEI
scholarship programs. 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 YVONNE CAROL SUMA-OY BARUC Date Signed ________________________

Father's Signature Or Mother's Signature Or Legal Guardian's Signature

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 only) ATTACHED DOCUMENTS WERE
VERIFIED FOR COMPLETENESS BY:
Form C - Certificate of Good Moral Character

Form D - Certification of Good Health

Form E1 - Principal’s Certification (for Applicant from the STEM Strand)

_______________________________
Form E2 - Principal’s Certification (for Applicant from the NON-STEM Strand) Printed Name/Signature
Form F - Certificate of Residency (for RA 7687 Applicants only)

Form G - Parent's Certification (if no pending application for immigration)

Form H - Applicant's Certification Date of Review of Documents: ____________

Form I - Signed Declaration by Applicant and the Parent/Legal Guardian

Two recent (1" x 1") pictures

Photocopy of Birth Certificate Date of Return of Applicant: ______________

Parent/s 2018 Income Tax Return / W2 / Employment Contract for OFW / BIR Certificate of Exemption
for Filing of ITR / Municipal or Barangay Certificate of Indigency (for RA 7687 Applicants only)
Electric Bills for 3 consecutive months in 2019 (for RA 7687 Applicants only) Remarks:
Affidavit of guardianship (If with Legal Guardian)

Certificate of scholarship in high school (if applicable)

High School Statement of Account (if applicable)

Others: ______________________________________________________