SCIENCE EDUCATION INSTITUTE Application ID: eFCEXq7e

DEPARTMENT OF SCIENCE AND TECHNOLOGY Email: [email protected]

2021 UNDERGRADUATE SCHOLARSHIPS ONLINE APPLICATION FORM

Applicant: NATHALIE PAQUERA SERAFIN

FORM C – CERTIFICATE OF GOOD MORAL CHARACTER

TO WHOM IT MAY CONCERN:

This is to certify that _________________________________________________

NATHALIE PAQUERA SERAFIN 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:

NATHALIE PAQUERA SERAFIN

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

TO WHOM IT MAY CONCERN:

NATHALIE PAQUERA SERAFIN

This is to certify that ______________________________________________ is a member of the Grade 12 graduating class under
(Name of Applicant)

POLYTECHNIC COLLEGE OF DAVAO DEL SUR /

MC ARTHUR HIGHWAY, KIAGOT ZONE 1 DIGOS CITY DAVAO DEL SURfor the SY 2020-2021.
The STEM Strand of the ___________________________________________________________________
(Name of School/Address)

_______________________________________________
Printed Name & Signature of Principal

Date: __________________________________________

FORM F – CERTIFICATE OF RESIDENCY

TO WHOM IT MAY CONCERN:

NATHALIE PAQUERA SERAFIN

This is to certify that ________________________________________________________________________ is a bonafide resident of
(Name of Applicant)
1ST CRUMB RAVINA COMPOUND ZONE 1 DIGOS C
ITY DAVAO DEL SUR
____________________________________________________________ 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, _________________________________________________,

NATHALIE PAQUERA SERAFIN 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: _____________________________________ _____________________________________

NATHALIE PAQUERA SERAFIN
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 ______________