Application No.

DEPARTMENT OF SCIENCE AND TECHNOLOGY

SCIENCE EDUCATION INSTITUTE
Bicutan, Taguig City

APPLICATION FORM

CAPACITY BUILDING PROGRAM IN SCIENCE AND MATHEMATICS

EDUCATION (CBPSME)

School Term: [✓ ] First [ ] Second [ ] Third Semester/Trimester

Academic Year

Form 1. Information Sheet

I. PERSONAL DATA

1. Name of Applicant: NACHOR PAOLO DELOS SANTOS

Last Name First Name Middle Name
2. Sex [✓ ] Male [ ] Female 3. Age 28 4. Nationality Filipino

5. Permanent Address: Jose Perez St. Calauag District 3

No./Street Village/Barangay Congressional District

Naga city Camarines Sur 4400 Region V

City/Municipality Province Zip Code Region

6. Residence Phone No.: +639810444964 7. Mobile Phone No.: +639455385912

8. Email Address : [email protected]
9. Date of Birth: October 24,1994 10. Place of Birth: Presentacion,Camarines Sur
11. Civil Status: Single
If married, Spouse’s Name: N/A. Occupation:. N/A
Business Address: N/A

Phone No.: N/A No of Children: NA

II. EDUCATIONAL BACKGROUND

LEVEL SCHOOL DEGREE YEAR GENERAL HONOR/S

EARNED GRADUATED WEIGHTED RECEIVED
AVERAGE
(GWA)
Baccalaureate Bicol state Bachelor of 2020 1.7 N/A
College of science in
applied science Secondary
and technology education major
in Mathematics
Master’s

Title of Thesis

Baccalaureate A Tracer Study of the Bicol state college of applied Science and Technology graduates of
BSED program batch 2018 and their employability status.
Master’s

III. EMPLOYMENT DATA

1. Present Employment Status: ( ) Permanent ( ) Contractual

( ) Probationary ( ) Self-employed
( ✓) Unemployed
1.a If currently employed

Position: Length of Service in Years

Name of Institution:

Address of Institution:

Email Address of Institution:

Telephone No/s:

Name of Head of Institution:

Official Designation of Head + Institution

2. Employment History
 If employed by the Department of Education (DepEd), please accomplish Form 2A.
 Please attach copy of Service Record/s or Certificate/s of Employment.

NAME OF INSTITUTION/COMPANY DATE OF EMPLOYMENT POSITION

Quantrics Interprises Inc Feb 2020-Jan 2021 Customer Service
Representative
Smartmind Tutorial Center Nov 2022-March 2023 Math Tutor

Gateway Visa Solution Jan 2023-April 2023 Document processor

IV. CAREER PLANS
Write in the attached sheet (Annex A).

Discuss your future plans after graduation. (Please check the last page)

V. DOST-SEI SCHOLARSHIP PROGRAM INFORMATION

If you have previously availed of any of the DOST-SEI scholarship programs, please
indicate below:

Scholarship Program Year of Degree Program/ Year

Please check Award Completed
Merit
RA 7687
Project 8102 Ed/9001 Ed
JLSS-Merit
✓ JLSS-RA 7687 2018 Bachelor in Secondary Education major in
Mathematics
JLSS-RA 10612
Faculty Development Program for
Teacher Education Institutions (TEIs)
ASTHRDP-Science Education
CBPSME
STRAND

VI. SCHOLARSHIP INTENTION

1. What type of Graduate Scholarship Program are you applying for?? [✓]

Master’s [ ] Doctoral

2. Field of Specialization: Master of Arts in Mathematics Education.

(Refer to the brochure and specify)

3. Indicate the university where you intend to enroll in (You are advised to seek
admission at the university where you intend to enroll in.):

Ateneo de Manila University

✓ Bicol University
Central Luzon State University
Cebu Normal University
De La Salle University
Leyte Normal University
Mariano Marcos State University
Mindanao State University-Iligan Institute of Technology
Mindanao State University-Marawi
Philippine Normal University
Saint Mary’s University
University of San Carlos
UP Open University
UP Diliman College of Education
Western Mindanao State University
West Visayas State University
 4. Have you been admitted to the Graduate School at any of the identified universities? [✓]

Yes [ ] No

5. Intended start of program of study:

[✓] First Semester [ ] Second Semester AY 2023- 2024_

6. For Lateral Applicant: 6a.

Total Number of Required Units in Your Program

Number of Units Already Earned
Remaining
Please submitUnits to be Taken
Certification from the university indicating the following:
General Weighted
• number Average
of graduate units required in the program
• number of graduate units already earned with corresponding grades

6b. Have you started working in your thesis/dissertation? [ ] Yes [ ] No

6c. If your is Yes in #6b, has your research topic been approved by the panel? [ ]
Yes [ ] No

If your answer is Yes, please attach the Approval Sheet and the Timeline of your
research activities.

6e. Thesis/Dissertation Topic

6f. What DOST priority research thrust is your research topic aligned with?
Explain how.

VII. RESEARCH INVOLVEMENT

1. Research conducted in the last 3 years. Use additional sheet if necessary.

AREA AND TITLE OF LOCATION/ FUND NATURE OF

RESEARCH DURATION SOURCE INVOLVEMEN
T
A Tracer Study of the Bicol state Naga city/1 year Self funded Group Member
college of applied Science and
Technology graduates of BSED
program batch 2018 and their
employability status.
 2. Discuss your proposed topic/research area/s of interest for your
thesis/dissertation. Use separate sheet (Annex B).

Note: The research proposal must be aligned with the priority research thrusts identified in the
DOST Harmonized National Research and Development Agenda (HNRDA). Refer to the
DOST website, www.dost.gov.ph

VIII. PUBLICATIONS
Use additional sheet if necessary.

TITLE OF TECHNICAL TITLE DATE NATURE OF

PAPER OF PUBLICATION PUBLISHED INVOLVEMEN
T
-----N/A----

IX. AWARDS AND RECOGNITION RECEIVED

Use additional sheet if necessary.

YEAR OF
TITLE OF AWARD AWARD GIVING BODY
AWARD
-------N/A------

X. TRUTHFULNESS OF DATA/DATA PRIVACY

I hereby certify that all information given above are true and correct to the best of my
knowledge. Any misinformation or withholding of information will automatically disqualify me from
the program, Capacity Building Program in Science and Mathematics Education. I am willing to
refund all the financial benefits received plus appropriate interest if such misinformation is
discovered.

Moreover, I hereby authorize the Science Education Institute of the Department of Science
and Technology (SEI-DOST) to collect, record, organize, update or modify, retrieve, consult, use,
consolidate, block, erase or destruct my personal data that I have provided in relation to my
application to this scholarship. I hereby affirm my right to be informed, object to processing, access
and rectify, suspend or withdraw my 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.

Signature over Printed Name of Applicant

Date
Application No.

Form 2A CERTIFICATE OF DEPED EMPLOYMENT AND PERMIT TO GO ON STUDY

LEAVE (For applicant who is employed by the Department of Education)

This is to certify that Ms./Mr. ,

an applicant of the CBPSME scholarship program, is a permanent employee of the
Department of Education for years.
(no. of years)

Should she/he qualify for the scholarship, she/he will be allowed to take a study full-
time for a period of two/three years while on scholarship.

Principal Schools Division Superintendent

Name of School School Division

Date Date

Regional Director
DepEd Regional Office No.
Date

Form 2B CERTIFICATE OF EMPLOYMENT, AND PERMIT TO GO ON STUDY LEAVE

(For applicant who is employed by private school)

This is to certify that Ms./Mr. ,

an applicant of CBPSME scholarship program, is a permanent employee of under the .
Name of School/Institution

Should she/he qualify for the scholarship, she/he will be allowed to take a leave of
absence from work and be released from institutional responsibilities to study full-time
for a period of two/three years while on scholarship.

Principal

Name of School
Date
Application No.

Form 3. MEDICAL CERTIFICATE

Date

TO WHOM IT MAY CONCERN:

This is to certify that I have examined Paolo D. Nachor and found

(Name of Applicant)
him/her to be physically and mentally fit to undergo graduate studies.

This certification is issued in connection with his/her application for scholarship under the
Capacity Building Program in Science and Mathematics Education.

Name (Print) and Signature of Licensed Physician

PRC License No.

Health Agency
Address

CHECKLIST OF DOCUMENTS TO BE SUBMITTED

Accomplished Application Form (Form 1)

Certificate of DepEd Employment and Permit to Go on Study Leave (Form 2A); OR Certificate of Employment and
Permit to Go on Study Leave Form 2B)
Medical Certificate (Form 3)
Birth Certificate (Photocopy)
Certified Copy of the Official Transcript of Records (TOR)
Certified True Copy of Service Record
Notice of Admission to Graduate School in any of the NCGSME member-universities
Career Plan (Annex A)
Career Plan (Annex B)
Endorsement from Former Professor 1
Endorsement from Former Professor 2
Commitment to Complete the Degree
Valid NBI Clearance
Letter of Nomination/Recommendation from the Head of the School/University
Approval Sheet of Thesis/Dissertation Research Topic
Timeline of Thesis/Dissertation Research Activities
For lateral entrant, certification from the university indicating the following:
• number of graduate units required in the program
• number of graduate units already earned with corresponding grades
 Application No.

CAPACITY BUILDING PROGRAM IN SCIENCE AND MATHEMATICS EDUCATION

Annex A

Name of Applicant Paolo D. Nachor Type of Scholarship Applying for

[✓] Master’s [ ] Doctoral

Date

CAREER PLANS(Annex A)
In not more than 500 words, discuss your career plan after graduation from your master’s/ doctoral degree.

To be a Master’s degree graduate of the Bicol University, the most prestigious university in Bicol, is such a great honor if
that happens. Not only is the BU graduate school my dream school, along with the University of the Philippines,but because
this school preserves its quality and affordability through all these years of serving the bicolanos along its high class
education and research program. Being a Master’s degree holder will open new opportunities for me. Moreover, my master's
degree can help me apply as an instructor to various colleges and universities, as this is one of the main eligibility
requirements to teach in higher educational institutions. This honor can also help me earn significant points as I am also
planning to apply as a Dep-Ed teacher in my home town of Presentacion, Camarines Sur. Furthermore, getting a master's
degree is such an advantage under the PPST based newly revised ranking system of the Department of Education as of 2023.
Being said that, a master's degree can give me great employability and provide skills that an undergraduate course can’t teach
you. But more importantly, if I am given the opportunity, I will share with my future students the discipline and knowledge
that come with being a Masters Graduate of the Bicol University and help students to become instrumental to nation building.