HUMAN RESOURCES DEVELOPMENT PROGRAM
Philippine Council for Advanced Science and Technology Research and Development
Department of Science and Technology
Rm. 100 DOST Main Bldg., General Santos Avenue, Bicutan, Taguig, Metro Manila
Tel. Nos. 837-20-71 to 82 Locals 2100-2109; Direct Lines 837-75-16/22; Fax No. 837-31-68
Email: [email protected] Website: http://www.pcastrd.dost.gov.ph
APPLICATION FORM
(Print or type in block letters)
Name : _________________________________________________________________________
(Family) (First) (Middle)
Program Applied For:
[ ] MS [ ] Thesis [ ] Research Fellowship
[ ] PhD [ ] Dissertation [ ] Visiting Professorship
Type of Scholarship:
[ ] Full-time [ ] Part-time
Proposed Field of Study:
[ ] Biology [ ] Computer Science [ ] Chemistry
[ ] Physics [ ] Information Technology [ ] Microelectronics
[ ] Mathematics [ ] Materials Science [ ] Statistics
[ ] Earth Science/Remote Sensing
Proposed Research Area:_____________________________________________________________
PCASTRD accredited school where admitted:__________________________________________
Type of Entry to the Scholarship:
[ ] Regular [ ] Lateral If lateral, no. of graduate units passed ______
Duration:_______________________________________________________________________
(for lateral entrants, to be supported by a certification from the graduate school on the minimum
number of units required and the minimum number of semesters needed to finish the degree)
Please submit this duly accomplished application form with the following requirements;
1. Certificate of acceptance/admission from any PCASTRD accredited school
2. Certified true copy of Transcript of Records (BS for MS applicant/BS and MS for PhD
applicant)
3. Certified true copy of diploma/certificate of graduation
4. Recommendation letters from two former professors (BS or MS, as the case may be)
5. Endorsement letter from the head of sending institution (where applicable)
a.
potential contribution
b.
length of service
c.
absence of criminal/administrative charges
d.
willingness to release the nominee from the duties and responsibilities for the
duration of the scholarship program/approved study leave with pay/ no existing
scholarship grant
6. Certified true copy of birth certificate
7. Doctor’s certification of good health with x-ray results
8. NBI Clearance
9. Two (2) copies of 2”x2” latest picture
10. Others
Revised 10/23/2008 1
Brief Description of Career Plans:
(use additional sheet if necessary)
PERSONAL INFORMATION
Home Address : ___________________________________________________________________
____________________________________________________________________
Home Tel. No. : ____________________________________________________________________
City/Contact Address : ____________________________________________________________
_______________________________________________________________
City/Contact Nos.:__________________________________________________________________
E-mail: ___________________________________ Mobile Phone No. ____________________
Sex : ____________________ Age : ___________ Civil Status : ___________________________
Date of Birth : ________________ Place of Birth : __________________ Citizenship :__________
If Married, Spouse Name : ___________________________________________________________
Occupation: _______________________________________________________
Employer :_____________________________________________________
Office Address : ____________________________________________________
Tel. Nos:__________________________________________________________
Children:
Name Age Address Occupation
_____________________ ________ _______________________ __________________________
_____________________ ________ _______________________ __________________________
_____________________ ________ _______________________ __________________________
_____________________ ________ _______________________ __________________________
_____________________ ________ _______________________ __________________________
Father’s Name : ___________________________ Occupation : ______________________________
Employer :____________________________________________________________________
Office Address : ____________________________________________________________________
Tel. No. :____________________________________________________________________
Mother’s Name : __________________________ Occupation : ______________________________
Employer :____________________________________________________________________
Office Address : ____________________________________________________________________
Tel. No. :____________________________________________________________________
Revised 10/23/2008 2
Brothers/Sisters :
Name Age Address Occupation
__________________________ _____ ___________________________ ______________________
__________________________ _____ ___________________________ ______________________
__________________________ _____ ___________________________ ______________________
__________________________ _____ ___________________________ ______________________
__________________________ _____ ___________________________ ______________________
__________________________ _____ ___________________________ ______________________
__________________________ _____ ___________________________ ______________________
(use additional sheets if necessary)
EDUCATIONAL BACKGROUND
Degree Received Name of Institution Year Title of Thesis
Special Trainings Undertaken:
Training Courses Training Institution Period
(use additional sheet if necessary)
Scholarship/Fellowship Availed of:
Program Field of Study School Sponsoring Inst. Period
(use additional sheet if necessary)
EMPLOYMENT RECORD
Present Employer :______________________________________________________________
Office Address: ____________________________________________________________________
Office Tel. No.:____________________________________________________________________
Brief Description of Present Duties:
(use additional sheet if necessary)
Revised 10/23/2008 3
Will your present employer pay your salary throughout the duration of your scholarship?
[ ] Yes [ ] No
Research Projects Involved In:
Title Name of Co-Researchers Period
(use additional sheet if necessary)
Please list positions held from previous employment:
Period Position Salary Employer
(use additional sheet if necessary)
Will you relocate your family within the proximity of the school you are enrolled?
[ ] Yes [ ] No
Character References : (preferably from your present office)
Name Position Address Contact Nos.
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
I certify that the statements made herein are true and correct and I promise to abide by the decision of
the PCASTRD administration on this application.
_______________________ ____________________________________
Date Signature of Applicant
Revised 10/23/2008 4
