Republic of the Philippines
Department of Science and Technology
SCIENCE EDUCATION INSTITUTE
2024 DOST-SEI SCIENCE AND TECHNOLOGY
UNDERGRADUATE SCHOLARSHIPS APPLICATION
FORM
FORM C – CERTIFICATE OF GOOD MORAL CHARACTER
TO WHOM IT MAY CONCERN:
This is to certify that Ma. Fatima W. Daiz
(Name of Applicant)
has consistently maintained good moral character, there having no disciplinary action
taken against him/her as of the date of application.
Printed Name & Signature of Principal/Guidance Counselor
Date:
NOTE: Should the Applicant be considered a potential qualifier, failure to maintain good moral character
before the scholarship is awarded may be a cause for disqualification. DOST-SEI may require
another Certification of Good Moral Character.
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Republic of the Philippines
Department of Science and Technology
SCIENCE EDUCATION INSTITUTE
2024 DOST-SEI SCIENCE AND TECHNOLOGY
UNDERGRADUATE SCHOLARSHIPS APPLICATION
FORM
FORM D – CERTIFICATION OF GOOD HEALTH
TO WHOM IT MAY CONCERN:
This is to certify that Ma. Fatima W. Daiz is of good
(Name of Applicant)
health and is fit to study in college.
Ma. Fatima W. Daiz
Printed Name & Signature
Designation
(i.e., Private/Barangay Health Center Physician/Nurse/Midwife)
License No.
Date
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Republic of the Philippines
Department of Science and Technology
SCIENCE EDUCATION INSTITUTE
2024 DOST-SEI SCIENCE AND TECHNOLOGY
UNDERGRADUATE SCHOLARSHIPS APPLICATION
FORM
FORM E1 – PRINCIPAL'S CERTIFICATION (For Applicant from the STEM Strand)
TO WHOM IT MAY CONCERN:
This is to certify that Ma. Fatima W. Daiz is a member of the Grade 12
(Name of Applicant)
graduating/graduated class under the STEM Strand of the Guiuan National High School
(Name of School/Address)
for SY 2023-2024 .
Benjamin P. Campomanes
Printed Name & Signature of Principal
Date
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Republic of the Philippines
Department of Science and Technology
SCIENCE EDUCATION INSTITUTE
2024 DOST-SEI SCIENCE AND TECHNOLOGY
UNDERGRADUATE SCHOLARSHIPS APPLICATION
FORM
FORM F – CERTIFICATE OF RESIDENCY
TO WHOM IT MAY CONCERN:
This is to certify that Ma. Fatima W. Daiz is a bonafide resident
(Name of Applicant)
of B r g y . C a m p o y o n g , G u i u a n , E a s t e r n S a m a r for
less than 4 years.
(House No./Unit No./Lot/Block/Bldg., Compound/Street/Phase/Purok, Village/Subdivision, Barangay, City/Municipality, Province) 4 years or more.
(Check appropriate box)
Printed Name & Signature of Barangay Official/Principal
Date
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Republic of the Philippines
Department of Science and Technology
SCIENCE EDUCATION INSTITUTE
2024 DOST-SEI SCIENCE AND TECHNOLOGY
UNDERGRADUATE SCHOLARSHIPS APPLICATION
FORM
FORM G – PARENT'S CERTIFICATION
This is to certify that my son/daughter/spouse, Ma. Fatima W. Daiz ,
(Name of Applicant)
has no pending application for immigration to the USA or any other country.
Luz. W. Daiz
Printed Name & Signature of Parent/Legal Guardian/Spouse
Date November, 17, 2023
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Republic of the Philippines
Department of Science and Technology
SCIENCE EDUCATION INSTITUTE
2024 DOST-SEI SCIENCE AND TECHNOLOGY
UNDERGRADUATE SCHOLARSHIPS APPLICATION
FORM
FORM H – DOST-SEI SCHOLARSHIP EXAMINATION/AWARD
This is to certify that the undersigned has: (check appropriate box)
NOT applied for a DOST-SEI scholarship before;
Applied for a DOST-SEI scholarship before but did not qualify for the scholarship.
Qualified for the DOST-SEI Undergraduate Scholarship but did not avail of the award.
Ma. Fatima W. Daiz
Printed Name & Signature of Applicant
Date November17,2023
Noted by: Luz. W. Daiz
Printed Name & Signature of Parent/Guardian/Spouse
Date November 17,2023
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Republic of the Philippines
Department of Science and Technology
SCIENCE EDUCATION INSTITUTE
2024 DOST-SEI SCIENCE AND TECHNOLOGY
UNDERGRADUATE SCHOLARSHIPS APPLICATION
FORM
FORM I – APPLICANT’S CERTIFICATION OF NO POST-SECONDARY
UNITS EARNED
This is to certify that the undersigned has NOT earned any college or post-high school vocational
units and will not earn the same in AY 2023-2024.
Ma. Fatima W. Daiz
Printed Name & Signature of Applicant
Date November 17,2023
Noted by: Ma. Fatima W. Daiz
Printed Name & Signature of Parent/Guardian/Spouse
Date November 17,2023
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Republic of the Philippines
Department of Science and Technology
SCIENCE EDUCATION INSTITUTE
2024 DOST-SEI SCIENCE AND TECHNOLOGY
UNDERGRADUATE SCHOLARSHIPS APPLICATION
FORM
FORM J - SIGNED DECLARATION OF APPLICANT AND THE PARENT/LEGAL GUARDIAN
We, the Applicant and my Parent/Legal Guardian/Spouse, hereby certify to the truthfulness
and completeness of information provided. Any misinformation, misrepresentation or
withholding of information will automatically disqualify me/our son/daughter/my spouse
from the Department of Science and Technology-Science Education Institute (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/spouse 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 DOST-SEI 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.
Ma. Fatima W. Daiz
Applicant’s Signature over Printed Name
Date November 17,2023
Luz. W. Daiz
Parent/Legal Guardian/Spouse Signature over Printed Name
Date November 17, 2023
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