STSD-201.
1
Rev. 0/11-09-15
DEPARTMENT OF SCIENCE AND TECHNOLOGY
SCIENCE EDUCATION INSTITUTE
Bicutan, Taguig City
APPLICATION FORM
for the
ACCELERATED SCIENCE & TECHNOLOGY HUMAN RESOURCE
DEVELOPMENT PROGRAM NATIONAL SCIENCE CONSORTIUM
2016-2017 GRADUATE SCIENCE AND TECHNOLOGY SCHOLARSHIPS
Attach here
1 latest passport
size picture
TYPE OF SCHOLARSHIP APPLIED FOR
MS
PHD
THESIS
DISSERTATION
I. PERSONAL INFORMATION
a.
Last Name
First Name
Middle Name
b.
Permanent Address
No.
Street
City/Municipality
Province
Zipcode
Region
District
Passport No.
E-mail Address
c.
d.
Current Mailing Address
.
e.
Telephone Nos. (Landline/Mobile)
Fax No.
Civil Status
Age
f.
Date of Birth
Sex
g.
Fathers Name
Mothers Name
II. EDUCATIONAL BACKGROUND
PERIOD
(Year Started
Year Ended)
FIELD
UNIVERSITY/
SCHOOL
SCHOLARSHIP
(if applicable)
REMARKS
PSHS
OTHERS:____________
PSHS
RA 7687
MERIT
JLAP
OTHERS:____________
NSDB/NSTA
ASTHRDP
ERDT
COUNCIL/SEI
OTHERS:____________
HS
BS
MS
NSDB/NSTA
ASTHRDP
ERDT
COUNCIL/SEI
OTHERS:____________
PHD
III. GRADUATE SCHOLARSHIP INTENTIONS DATA
st
(Note: An applicant for a graduate program should elect to go to another university if he/she earned his/her 1 (BS)
nd
and/or 2 (MS) degrees from the same university to avoid inbreeding.)
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
Applicant for Thesis/Dissertation Grant (Please fill-up also information for Lateral Applicant)
Has your research topic been approved by the panel?
YES
NO
Title
Date of last enrolment for thesis/dissertation
IV. CAREER/EMPLOYMENT INFORMATION
a. Present Employment Status
( ) Permanent
( ) Self-employed
( ) Contractual
( ) Unemployed
a.1 For those who are presently employed*
Position
( ) Probationary
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 take 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
VI. PUBLICATIONS (last five years)
Use additional sheet if necessary.
TITLE OF ARTICLE/PUBLICATION
VII. AWARDS RECEIVED
TITLE OF AWARD
FUND SOURCE
NATURE OF INVOLVEMENT
PLACE/YEAR OF PUBLICATION
NATURE OF INVOLVEMENT
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 __________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------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 take 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
DEADLINE OF SUBMISSION OF APPLICATION
UNIVERSITY
1ST TERM
2ND TERM
3RD TERM
USC
May 31
September 15
ADMU, CLSU, MSU-IIT, UPD,
UPLB, UPM, UPV, UST and VSU
June 15
November 15
DLSU
March 31
ACCELERATED SCIENCE & TECHNOLOGY HUMAN RESOURCE DEVELOPMENT PROGRAM
NATIONAL SCIENCE CONSORTIUM
2016-2017 GRADUATE SCIENCE AND TECHNOLOGY SCHOLARSHIPS
Name of Applicant:
_____________________________________________
Date:
_____________________________________________
CAREER PLANS
b.1) Briefly discuss your proposed research area/s
----------------------------------------------------------------------------------------------------------------------------------------------------------------------b.2) Future Plans (After Graduation)
