2021 Undergraduate Scholarships Online Application Form Form C - Certificate of Good Moral Character

SCIENCE EDUCATION INSTITUTE Application ID: KJwZfyII
DEPARTMENT OF SCIENCE AND TECHNOLOGY Email: [email protected]
2021 UNDERGRADUATE SCHOLARSHIPS ONLINE APPLICATION FORM

Applicant: JOHN LLOYD PALOMAR ROSARIO
FORM C – CERTIFICATE OF GOOD MORAL CHARACTER
TO WHOM IT MAY CONCERN:
This is to certify that _________________________________________________

JOHN LLOYD PALOMAR ROSARIO 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
JOHN LLOYD PALOMAR ROSARIO

This is to certify that __________________________________________________ is of good health; and can take the DOST-SEI
(Name of Applicant)
Undergraduate Scholarship Examination on his/her own.
_________________________________________
Printed Name & Signature of School/Barangay Health
Center/Private Physician/Nurse
License No.:_________________________________________
Date: ______________________________________________
FORM E2 – PRINCIPAL’S CERTIFICATION (For Applicant from the NON-STEM Strand)

This is to certify that ______________________________________________ is a member of the Grade 12 graduating class under
(Name of Applicant)
The NON-STEM Strand for the SY 2020-2021 and is classified within the upper five percent of _________ students in the graduating class.
(Total Number of Graduation Students)
_____________________________________________
NOTE: Please certify based on applicant’s academic standing as of grade 11 Printed Name & Signature of Principal
(i.e., top 5% of his/her class)
Date: ________________________________________
FORM F – CERTIFICATE OF RESIDENCY

This is to certify that ________________________________________________________________________ is a bonafide resident of
(Name of Applicant)
#83 BOGTONG CENTRO BOGTONG BOLO MANGATAR
EM PANGASINAN
____________________________________________________________ for less than 4 years / ✔ 4 years or more.
(Permanent Address) (Check appropriate box)
_______________________________________________
Printed Name & Signature of Barangay Official/Principal
Date: _________________________________________
FORM G – PARENT’S CERTIFICATION
This is to certify that my son/daughter, _________________________________________________,

JOHN LLOYD PALOMAR ROSARIO has no pending application for
(Name of Applicant)
immigration to the USA or any other country.
_____________________________________
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 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:
We hereby certify to the truthfulness and completeness of information provided. Any misinformation, misrepresentation or withholding
of information will automatically disqualify m e/our son/daughter from the DOST-SEI Scholarship Program. 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, we hereby authorize the DOST-SEI designated representative to conduct a background
check on our socio-economic status and to visit our family dwelling.
Moreover, we hereby express 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 our personal data as part of our
information. We hereby affirm our right to be informed, object to processing, access and rectify, suspend or withdraw 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

Over Printed name _____________________ Or Over Printed name ___________________ Or Over Printed name ______________

2021 Undergraduate Scholarships Online Application Form Form C - Certificate of Good Moral Character

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SCIENCE EDUCATION INSTITUTE Application ID: KJwZfyII

DEPARTMENT OF SCIENCE AND TECHNOLOGY Email: [email protected]

2021 UNDERGRADUATE SCHOLARSHIPS ONLINE APPLICATION FORM

FORM C – CERTIFICATE OF GOOD MORAL CHARACTER

TO WHOM IT MAY CONCERN:

This is to certify that _________________________________________________

FORM D – CERTIFICATION OF GOOD HEALTH

TO WHOM IT MAY CONCERN:

JOHN LLOYD PALOMAR ROSARIO

Undergraduate Scholarship Examination on his/her own.

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

TO WHOM IT MAY CONCERN:

JOHN LLOYD PALOMAR ROSARIO

FORM F – CERTIFICATE OF RESIDENCY

TO WHOM IT MAY CONCERN:

JOHN LLOYD PALOMAR ROSARIO

This is to certify that my son/daughter, _________________________________________________,

immigration to the USA or any other country.

FORM H – APPLICANT’S CERTIFICATION

This is to certify that the undersigned has:

✔ NOT taken any previous DOST-SEI Undergraduate Scholarship examination.

✔ NOT earned any post-secondary or undergraduate units.

Noted by: _____________________________________ _____________________________________

Date: ______________________________________ Date: ________________________________________

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

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

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Noted by: _ _

Date: Date: __