DEPARTMENT OF SCIENCE AND TECHNOLOGY

SCIENCE EDUCATION INSTITUTE

Bicutan, Taguig City

APPLICATION FORM
for the Attach here
1 latest passport
SCIENCE AND TECHNOLOGY REGIONAL ALLIANCE OF UNIVERSITIES size picture
FOR INCLUSIVE NATIONAL DEVELOPMENT
(Project STRAND)
GRADUATE SCIENCE AND TECHNOLOGY SCHOLARSHIPS
AY 2017-2018

Form 1

I. PERSONAL INFORMATION
a.
Last Name First Name Middle Name
b.
Permanent Address No. Street Baranggay City/Municipality Province
c.
Zipcode Region District Passport No. E-mail Address
d.
Current Mailing Address
e.
Telephone Nos. (Landline/Mobile) Fax No.
f.
Civil Status Date of Birth Age Sex
g.
Father’s Name Mother’s Name

II. EDUCATIONAL BACKGROUND

PERIOD
UNIVERSITY/ SCHOLARSHIP
(Year Started – FIELD REMARKS
SCHOOL (if applicable)
Year Ended)
 PSHS
HS
OTHERS:____________
 PSHS
 RA 7687
BS  MERIT
 JLAP
OTHERS:____________
 NSDB/NSTA
 ASTHRDP
MS  ERDT
 COUNCIL/SEI
OTHERS:____________
 NSDB/NSTA
 ASTHRDP
PHD  ERDT
 COUNCIL/SEI
OTHERS:____________

III. GRADUATE SCHOLARSHIP INTENTIONS DATA

Notes: 1. An applicant for a graduate program should elect to go to another university if he/she earned his/her 1 st (BS)
and/or 2nd (MS) degrees from the same university to avoid inbreeding.
2. A faculty-applicant for a graduate program should elect to go to any of the member universities of the ASTHRDP
National Science Consortium, i.e., ADMU, CLSU, DLSU, MSU-IIT, UPD, UPLB, UPM, UPV, USC, UST and
VSU; or the ERDT Consortium, i.e., ADMU, CLSU, DLSU, MIT, MSU-IIT, UPD, UPLB, and USC.

STRAND CATEGORY TYPE OF APPLICANT (for STRAND 2 only) TYPE OF SCHOLARSHIP APPLIED FOR
STRAND 1 STRAND 2 Student Faculty MS PhD

New Applicant
a. University where you applied/intend
to enrol for graduate studies
b. Course/Degree
Lateral Applicant
a. University enrolled in
b. Course/Degree

c. Number of units earned d. No. of remaining units/sems

IV. CAREER/EMPLOYMENT INFORMATION
a. Present Employment Status ( ) Permanent ( ) Contractual ( ) Probationary
( ) Self-employed ( ) Unemployed
a.1 For those who are presently employed*
Position Length of Service
Name of Company/Office
Address of Company/Office
Email Website
Telephone No. Fax No.

a.2 For those who are self-employed

Business Name
Address

Email/Website Telephone No. Fax No.

Type of Business Years of Operation

*Once accepted in the scholarship program, the scholar must obtain permission to go on a Leave of Absence (LOA) from
his/her employer and become a full-time student. The scholar must submit a letter from his/her employer approving the
LOA.

b. CARRER PLANS (Write in the separate sheet attached to this form)

b.1 Briefly discuss your proposed research area/s
b.2 Future Plans (After Graduation)

V. RESEARCH AND DEVELOPMENT INVOLVEMENT (last five years)

Use additional sheet if necessary
FIELD AND TITLE OF RESEARCH LOCATION/DURATION FUND SOURCE NATURE OF INVOLVEMENT

VI. PUBLICATIONS (last five years)

Use additional sheet if necessary.
TITLE OF ARTICLE/PUBLICATION PLACE/YEAR OF PUBLICATION NATURE OF INVOLVEMENT

VII. AWARDS RECEIVED

TITLE OF AWARD AWARD GIVING BODY YEAR OF AWARD

I hereby certify that all information given above are true and correct to the best of my knowledge.

Signature of Applicant
Date __________________________
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CHECKLIST OF REQUIRED DOCUMENTS SUBMITTED (for staff use only)
 Birth Certificate (Photocopy)
 Certified True Copy of the Official Transcript of Record
 Endorsement from two former professors in college or from two former professors in the MS program
for applicant pursuing a PhD program
If Employed
 Recommendation from Head of Agency
 Permission to go on a leave of absence (LOA) while on scholarship
 Medical Certificate as to health status from a licensed physician with his/her PRC license number indicated
 Valid NBI Clearance
 Letter of Admission from the Graduate School which should include the evaluation sheet
 Program of Study
Distribution of Universities by Type of STRAND
STRAND 1 STRAND 2
BatStateU, CSU, EVSU, PSU, USM BatStateU, CMU, MMSU, MSU-IIT NVSU,
SLU, SMU, USEP, USTP CDO
 SCIENCE AND TECHNOLOGY REGIONAL ALLIANCE OF UNIVERSITIES
FOR INCLUSIVE NATIONAL DEVELOPMENT
(Project STRAND)
GRADUATE SCIENCE AND TECHNOLOGY SCHOLARSHIPS
AY 2017-2018

Name of Applicant: _____________________________________________

Date: _____________________________________________

CAREER PLANS
b.1) Briefly discuss your proposed research area/s

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b.2) Future Plans (After Graduation)
Form 2
(For those who are currently employed)

CERTIFICATION OF EMPLOYMENT AND PERMIT TO STUDY

Instructions to the Applicant: Please complete this form and give this to the Head of the
Institution/Supervisor for certification. Enclose the accomplished form in your application.

This is to certify that the person whose name appears below is employed in the
institution as indicated but is allowed to go on a leave of absence should he/she qualify
for a scholarship under Project STRAND.

Name of Applicant:

__________________________________________________________________
(Last Name) (First Name) (Middle Name)
Designation:_______________________________________________________________
Sending Institution: _________________________________________________________

Address:__________________________________________________________________
Program Applied for: ________________________________________________________

Issued upon the request of the applicant as a requirement for application DOST-SEI Graduate
Scholarship under the Science and Technology Regional Alliance for Inclusive National
Development (STRAND).

Signature of the Head of Institution: __________________________

Printed Name: ___________________________________ Date: ______________________

Position/Title: ____________________________________

Form 3

CERTIFICATION OF HEALTH STATUS

________________________
Date

TO WHOM IT MAY CONCERN:

This is to certify that I have examined ____________________________________ and

found him/her to be physically fit to undertake the graduate studies.

This certification is issued in connection with his/her application for the DOST-SEI
Graduate Scholarship under the Science and Technology Regional Alliance for Inclusive
National Development (STRAND).

_________________________________ _____________________________________
Name of Health Agency Name (Print) and Signature of Medical Officer

_________________________________ _____________________________________
Address Official Designation/License No.