Wlalang
FORM A
TO BE FILLED-OUT BY DOST/SEI STAFF ONLY TCC APPLN. NO.
__
Republic of the Philippines Department of Science and Technology SCIENCE EDUCATION INSTITUTE P.O. Box 18 Taguig Post Office
NOT FOR SALE CAN BE REPRODUCED ALL ENTRIES/SIGNATURE IN THIS FORM MUST BE ORIGINAL.
2011 Total Annual Family Gross Income: P (Taxable & Non-taxable) Month 1 __________ kwh Average Electricity Month 2 __________ kwh Consumption in kwh: Month 3 __________ kwh Total = __________ / 3 mos. CV = __________ kwh 4th Year Annual HS Net Tuition & Other School Fees: P Scholarship Program Assessment:
RA 7687 Merit P 200.00/O.R. No. ____________
INFORMATION SHEET for the
Attach recent 1” x 1” photo here
Assessed by: Printed Name/Signature SEI DOST RO. No.: ____
DOST-SEI SCIENCE AND TECHNOLOGY SCHOLARSHIPS FOR 2013
Once officially stamped, DO NOT detach photo. Attach another copy of the 1" x 1" photo for the Test Permit.
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. Deadline for Submission: 05 October 2012 (Friday) Date of Examination: 18 November 2012 (Sunday) I. PERSONAL DATA 1. Name of Applicant Surname Female 3. Date of Birth 6. Do you have a dual citizenship? Cell Phone No. Barangay City/Municipality Yes First Name 4. Place of Birth No If yes, please specify: Middle Name
2. Sex 5. Citizenship
Male
7. Contact Nos.: Landline Phone No. 9. Permanent Address No. Street
8. Email Address: LONE/1st/2nd/3rd/4th/5th/6th/7th District (encircle) Province Zip Code
10. Number of Children in the Family 12. Name of High School 13. Type of High School 14. Address of High School
Regular Public
11. Birth Order of Applicant (1st child, 2nd child, etc.)
Science
Private
High School Code (To be provided by DOST-SEI)
15. Tuition and Other School Fees Paid in a Private High
TO BE FILLED-OUT BY DOST/SEI STAFF ONLY TCC APPLN. NO.
__
Republic of the Philippines Department of Science and Technology SCIENCE EDUCATION INSTITUTE P.O. Box 18 Taguig Post Office
NOT FOR SALE CAN BE REPRODUCED ALL ENTRIES/SIGNATURE IN THIS FORM MUST BE ORIGINAL.
2011 Total Annual Family Gross Income: P (Taxable & Non-taxable) Month 1 __________ kwh Average Electricity Month 2 __________ kwh Consumption in kwh: Month 3 __________ kwh Total = __________ / 3 mos. CV = __________ kwh 4th Year Annual HS Net Tuition & Other School Fees: P Scholarship Program Assessment:
RA 7687 Merit P 200.00/O.R. No. ____________
INFORMATION SHEET for the
Attach recent 1” x 1” photo here
Assessed by: Printed Name/Signature SEI DOST RO. No.: ____
DOST-SEI SCIENCE AND TECHNOLOGY SCHOLARSHIPS FOR 2013
Once officially stamped, DO NOT detach photo. Attach another copy of the 1" x 1" photo for the Test Permit.
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. Deadline for Submission: 05 October 2012 (Friday) Date of Examination: 18 November 2012 (Sunday) I. PERSONAL DATA 1. Name of Applicant Surname Female 3. Date of Birth 6. Do you have a dual citizenship? Cell Phone No. Barangay City/Municipality Yes First Name 4. Place of Birth No If yes, please specify: Middle Name
2. Sex 5. Citizenship
Male
7. Contact Nos.: Landline Phone No. 9. Permanent Address No. Street
8. Email Address: LONE/1st/2nd/3rd/4th/5th/6th/7th District (encircle) Province Zip Code
10. Number of Children in the Family 12. Name of High School 13. Type of High School 14. Address of High School
Regular Public
11. Birth Order of Applicant (1st child, 2nd child, etc.)
Science
Private
High School Code (To be provided by DOST-SEI)
15. Tuition and Other School Fees Paid in a Private High