Application No: 2024 -

SCHOLARSHIP OFFERINGS FOR ASEAN RESEARCHERS Attach here one (1)

(Cambodia, Lao PDR and Myanmar-CLM)
recent 2x2 photo
Engineering and Science Programs for CLM Researchers
First Semester AY 2024-2025

SCHOLARSHIP APPLICATION FORM

I. PERSONAL INFORMATION

1. Name of Applicant: ______________________________________________________

Last Name First Name Middle Name

2. Permanent Address: ______________________________________________________

No. Street District
______________________________________________________
City/Municipality Province/Region Zip Code

3. E-mail Address: _________________________ 4. Residence Phone No: _______________

5. Mobile No: _________________________ 6. Fax No.: __________________________
7. Sex: ____ Female ______ Male 8. Age: ______ 9. Nationality: ___________
10. Date of Birth: ___________________________ 11. Place of Birth: _____________________
12. Civil Status: ____________________________
If married, Spouse’ Name:_____________________________________________________
Occupation: _______________________________________________________________
Business Address: __________________________________________________________
Phone No.: ___________________________ No. of Children: _______________________
13. Passport Details:
Passport Number: _________ Date of Issue: _________ Validity Period: __________
Place of Issue: _____________________________________________________________

II. EMPLOYMENT INFORMATION

14. Present Employment Status: ( ) Permanent ( ) Contractual ( ) Probationary

( ) Self-employed ( ) Unemployed
If presently employed
Position: ________________________________ Length of Service (in years): _____
Name of Institution: ____________________________________________________
Institution Address: ____________________________________________________
Head of Institution: ____________________________________________________
Telephone Number: ____________________ Fax No.: _____________________
E-mail Address: _______________________________________________________

III. EDUCATIONAL BACKGROUND

LEVEL SCHOOL DEGREE YEAR GENERAL HONORS

EARNED GRADUATED WEIGHTED RECEIVED
AVERAGE
(GWA)
Baccalaureate

Master’s
1

Thesis/Dissertation
Page

Title

*Please attach Certified True Copy of Transcript of Records.

Head Office: Gen. Santos Ave., Bicutan, Taguig City Postal Address: P.O. Box 3596 Manila
Website: www.dost.gov.ph Tel. No. (02) 8330-8876 | (02) 8330-8826
 Application No: 2024 -

IV. LANGUAGE ABILITY

Please rate your language proficiency from 1 (poor) to (3) acceptable to 5 (very good)

First Language: __________________ Other Languages: ___________________________

Spoken Understanding Written

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

English

Filipino

V. SCHOLARSHIP INTENTION

15. Applying for which type of Graduate Scholarship Program?

_____ Master’s
_____ PhD

16. Field of study

_____ Biology
_____ Chemistry
_____ General Science
_____ Mathematics
_____ Physics
_____ Engineering Specific Field: _____________

17. University you intend to enrol (You are advised to seek admission at the university where you
intend to enrol):

Sciences:
__________ De La Salle University (DLSU) (www.dlsu.edu.ph)
__________ University of the Philippines Los Banos (UP-Los Baños) (www.uplb.edu.ph)
__________ University of the Philippines Manila (UP-Manila) (www.upm.edu.ph)

Engineering:
__________ De La Salle University (DLSU) (www.dlsu.edu.ph)
__________ University of the Philippines-Los Banos (UP-Los Baños) (www.uplb.edu.ph)

18. Proposed Thesis/Dissertation Topic

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
*The topic will be presented to the research adviser for proposal defense and final approval of the panel to
determine and recommend an enabling mechanism for the student to complete the degree program on time.
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Page

Head Office: Gen. Santos Ave., Bicutan, Taguig City Postal Address: P.O. Box 3596 Manila
Website: www.dost.gov.ph Tel. No. (02) 8330-8876 | (02) 8330-8826
 Application No: 2024 -

VI. RESEARCH INVOLVEMENT (last three years)

FIELD AND TITLE NATURE OF

LOCATION/DURATION FUND SOURCE
OF RESEARCH INVOLVEMENT

Use additional sheet if necessary

VII. PUBLICATIONS

TITLE OF PLACE/YEAR OF NATURE OF INVOLVEMENT

ARTICLE/PUBLICATION PUBLICATION

Use additional sheet if necessary

VIII. AWARDS AND RECOGNITION RECEIVED

TITLE OF AWARD AWARD GIVING BODY YEAR OF AWARD

IX. CAREER PLANS (Write in the attached sheet)

a. Narrative of not more than 800 words describing your current work or project/research that
you worked on and your contribution towards the completion of the project (Annex A)
b. Narrative of not more than 300 words describing what you intend to do (e.g. work, business,
etc.) after earning your graduate degree (Annex B)
c. Narrative of not more than 500 words describing your intended research area (Annex C)

I hereby certify to the truthfulness and completeness of the information provided. Any misinformation
or withholding of information will automatically disqualify me from the Scholarship Program on
Science and Engineering for CLM Students offered by the Philippines under the ASEAN STI
Partnership Fund/Contributions. I am willing to refund all the financial benefits received plus
appropriate interest if such misinformation is discovered.

Moreover, I hereby express my consent for the DOST-SEI to collect, record, organize, update or
modify, retrieve, consult, use, consolidate, block, erase or destruct my personal data as part of my
information. I hereby affirm my right to be informed, object to processing, access, and rectify, suspend
or withdraw my personal data, and be imdemnified 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.

__________________________________
3

Signature over Printed Name of Applicant

Page

________________
Date
Head Office: Gen. Santos Ave., Bicutan, Taguig City Postal Address: P.O. Box 3596 Manila
Website: www.dost.gov.ph Tel. No. (02) 8330-8876 | (02) 8330-8826
 Application No: 2024 -

ANNEX A:

Narrative of not more than 800 words describing your current work or project/research that you
worked on and your contribution towards the completion of the project.

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Page

Head Office: Gen. Santos Ave., Bicutan, Taguig City Postal Address: P.O. Box 3596 Manila
Website: www.dost.gov.ph Tel. No. (02) 8330-8876 | (02) 8330-8826
 Application No: 2024 -

ANNEX B:

Narrative of not more than 300 words describing what you intend to do (e.g. work, business, etc.) after
earning your graduate degree.

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Page

Head Office: Gen. Santos Ave., Bicutan, Taguig City Postal Address: P.O. Box 3596 Manila
Website: www.dost.gov.ph Tel. No. (02) 8330-8876 | (02) 8330-8826
 Application No: 2024 -

ANNEX C:

Narrative of not more than 500 words describing your intended research area.

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Page

Head Office: Gen. Santos Ave., Bicutan, Taguig City Postal Address: P.O. Box 3596 Manila
Website: www.dost.gov.ph Tel. No. (02) 8330-8876 | (02) 8330-8826
 Application No: 2024 -

MEDICAL CERTIFICATE

_________________
Date

TO WHOM IT MAY CONCERN:

This is to certify that I have examined ____________________________________________

(Name of Applicant)
and found him/her to be physically and mentally fit to undergo the rigors of study.

This certification is issued in connection with his/her application for the Scholarship Offerings
for ASEAN Researchers (Cambodia, Lao PDR and Myanmar - CLM) offered by the Philippines under
the ASEAN STI Partnership Fund/Contributions.

__________________________________________
Name (Print) and Signature of Licensed Physician

______________________
License No.

___________________________________________________________
Health Agency

___________________________________________________________
Address

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Head Office: Gen. Santos Ave., Bicutan, Taguig City Postal Address: P.O. Box 3596 Manila
Website: www.dost.gov.ph Tel. No. (02) 8330-8876 | (02) 8330-8826
 Application No: 2024 -

Checklist of Documents to be Submitted

Accomplished Scholarship Application Form

Annexes A, B and C of the Scholarship Application Form
Medical Certificate (as attached in the form)
Endorsement Letter from the Sending Institution
Endorsement Letter from the Philippine Embassy
Recommendation Letter from Two (2) Former Professors or Supervisors
Certified True Copy of Transcript of Record (TOR)
Certified Letter on Academic Standing
Letter of Acceptance from the preferred university
Original and Photocopy of Birth Certificate
Original and Photocopy of Police Clearance
Certification from the Employer that the applicant is permitted to take leave of
absence (if applicant is employed)
Photocopy of valid passport

Deadline for Submission of Application:

Date: 18 June 2024

Accomplish online application form and upload required documents through

bit.ly/DocSubmissionCLM. Original copies of the documents must be submitted to the
Embassy of the Republic of the Philippines at the applicant’s home country on or before 18
June 2024:

Cambodia No. 182 Preah Norodom Blvd.

Sangkat Tonle Bassac, Khan Chamkarmon
Phnom Penh, Kingdom of Cambodia
E-mail Address: phnompenh.pe@dfa.gov.ph
pe.phnompenh.01@gmail.com

Lao PDR Embassy of the Republic of the Philippines, Lao PDR

Ban Saphanthong Neua, Phontan Rd.
Sisattanak District, Vientiane
Lao People’s Democratic Republic, P.O. Box 2415
E-mail Address: vientiane.pe@dfa.gov.ph

Myanmar: Embassy of the Republic of the Philippines, Myanmar

21 Pho Sein Road, Bahan Township
Yangon, Republic of the Union of Myanmar
E-mail Address: yangon.pe@dfa.gov.ph

Always cc:

ENGR. ALBERT G. MARIÑO

Director III and OIC
Science Education Institute-DOST
Email Address: agmarino@sei.dost.gov.ph
ppgavina@sei.dost.gov.ph
sfesquivel@sei.dost.gov.ph
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Page

Head Office: Gen. Santos Ave., Bicutan, Taguig City Postal Address: P.O. Box 3596 Manila
Website: www.dost.gov.ph Tel. No. (02) 8330-8876 | (02) 8330-8826