SCIENCE EDUCATION INSTITUTE
DEPARTMENT OF SCIENCE AND TECHNOLOGY
2020 JUNIOR LEVEL SCIENCE SCHOLARSHIPS ONLINE APPLICATION FORM
FORM C – CERTIFICATE OF GOOD MORAL CHARACTER
TO WHOM IT MAY CONCERN:
This is to certify that __________________________________________________________________ has consistently maintained
(Name of Applicant)
good moral character, there having no disciplinary action taken against him/her as of the date of application.
_______________________________________________
Printed Name & Signature of Dean of Student Affairs
Date: __________________________________________
NOTE: Failure to maintain good moral character before the award of the scholarship shall cause forfeiture thereof. DOST-SEI may require another certification before the signing of the
Scholarship Agreement should the applicant qualify.
FORM D – CERTIFICATION OF GOOD HEALTH
TO WHOM IT MAY CONCERN:
This is to certify that __________________________________________________ is of good health; and can take the DOST-SEI
(Name of Applicant)
Junior Level Science Scholarship Examination on his/her own.
_______________________________________________
Printed Name & Signature of School/Barangay Health
Center/Private Physician/Nurse
License No.: ____________________________________
Date: __________________________________________
FORM E – CERTIFICATION OF PROGRAM OF STUDY AND YEAR LEVEL
TO WHOM IT MAY CONCERN:
This is to certify that ________________________________________________________________________________ is enrolled in
(Name of Applicant)
Bachelor of Science in _______________________________________________________________ as a REGULAR SECOND YEAR student
(Program of Study)
for Second Semester AY _____2019-2020____ at the ________________________________________________________________.
(College/University)
_______________________________________________
Printed Name & Signature of College Dean/Registrar
Date: __________________________________________
NOTE: Potential qualifiers to the JLSS Scholarship Program will be required to submit a certification of Regular Third Year Standing in AY 2020-2021; proper notification will be
sent sometime in July – August 2020. Awarding of the scholarship shall be pending the submission of this requirement.
FORM F – CERTIFICATE OF RESIDENCY
TO WHOM IT MAY CONCERN:
This is to certify that ________________________________________________________________________ is a bonafide resident of
(Name of Applicant)
____________________________________________________________ for less than 4 years / 4 years or more.
(Permanent Address) (Check appropriate box)
_______________________________________________
Printed Name & Signature of Barangay Official/Principal
Date: _________________________________________
Application ID: O8Q2QZSA
Email: klentrojo@gmail.com
Applicant: KLENT JOSEPH NAYBE ROJO
KLENT JOSEPH NAYBE ROJO
KLENT JOSEPH NAYBE ROJO
KLENT JOSEPH NAYBE ROJO
Electrical Engineering
SURIGAO STATE COLLEGE OF TECHNOLOGY
KLENT JOSEPH NAYBE ROJO
Purok 2 Brgy. Sabang SURIGAO CITY SURIGAO DEL NORTE ✔
