2015 DOST-PHILIPPINE SCIENCE HIGH SCHOOL SYSTEM
NATIONAL COMPETITIVE EXAMINATION (NCE)
APPLICATION FORM
THESE MATERIALS ARE NOT FOR SALE. THEY
MAY BE PHOTOCOPIED AND MAY BE
DOWNLOADED FROM www.pshs.edu.ph
Instructions:
Please accomplish this form in two copies. Type or print legibly all information needed.
ABBREVIATE. DO NOT LEAVE ANY ITEM BLANK. Countersign all erasures and corrections made.
DEADLINE OF SUBMISSION:
Staple Only
DO NOT
1 x 1
Photo
August 24, 2015
PERSONAL DATA:
1) NAME OF PUPIL-APPLICANT: (Last Name, First Name, Middle Name)
2) BIRTHDATE:
3) AGE as of June 1, 2015:
6) EMAIL ADDRESS:
4) SEX:
MALE
5)
FEMALE
CONTACT
NUMBERS:
(pls. include all
possible contact
numbers)
7) COMPLETE HOME/ PERMANENT ADDRESS: (pls. include your zip code)
TO BE FILLED UP BY THE PARENTS:
CONSIDER THE
FOLLOWING WHEN
CHOOSING A
CAMPUS:
1. The score in the NCE
is the major basis for
qualifying
to
the
PSHS.
2. All examinees are
ranked from highest
to lowest. The top
240
qualifiers
irrespective of region
of origin will be
invited to enroll at
the Main Campus but
acceptance to the
invitation
is
not
compulsory.
YES NO
1.
2.
3.
4.
Is your child a Filipino citizen?
Does your child have a pending application as immigrant in any foreign country?
Has your child taken the PSHS National Competitive Examination before?
If not qualified in the Main Campus (MC), are you willing to enroll your child in a Regional Campus she/he will qualify in?
(If NO, your child will be considered for ranking ONLY in the MC, Quezon City.)
5. If YES in No. 4, check only one regional campus of your choice where you want to enroll your child.
(If you choose a regional campus, and your child does NOT qualify for the national 240 qualifiers, she/he will only be considered for
ranking in the regional campus of your choice.)
ILOCOS REGION San Ildefonso, Ilocos Sur
ZAMBOANGA PENINSULA Dipolog City
CAGAYAN VALLEY Bayombong, Nueva Vizcaya
CENTRAL LUZON Clark Freeport Zone, Pampanga
CENTRAL MINDANAO Balo-i. Lanao del Norte
SOUTHERN MINDANAO Tugbok, Davao City
CALABARZON Batangas City
MIMAROPA Odiongan, Romblon
BICOL REGION Goa, Camarines Sur
SOCCSKSARGEN Paraiso, Koronadal City
CORDILLERA ADMINISTRATIVE REGION Irisan, Baguio City
CARAGA Ampayon, Butuan City
WESTERN VISAYAS Jaro, Iloilo City
CENTRAL VISAYAS Argao, Cebu
I certify that the above information is true and correct.
I understand that any false or misleading information will
result to the disapproval of application/admission.
EASTERN VISAYAS Palo, Leyte
Signature over Printed Name of Parents
TO BE FILLED UP BY THE SCHOOL AUTHORITY CONCERNED:
1)
NAME OF SCHOOL (Write name of school in full):
3)
SCHOOL TYPE:
6)
Pupil-Applicants FINAL GRADE IN
SCIENCE (SY 2014-2015):
Public
Private
2)
COMPLETE SCHOOL ADDRESS:
4) GRADE LEVEL as of JUNE 2015:
5) SCHOOL
CONTACT NOS.:
7) Pupil-Applicants FINAL GRADE IN
8) Pupil-Applicants FINAL CHARACTER
MATHEMATICS (SY 2014-2015):
RATING (SY 2014-2015):
I hereby certify that the pupil-applicant is currently enrolled in Grade 6 for SY 2015-2016.
Signature over Printed Name of Principal/ School Head/ Registrar/ Teacher
(PLEASE DO NOT DETACH)
This serves as a proof of application. IMPORTANT: This DOES NOT serve as the test permit.
NAME OF PUPIL-APPLICANT: _______________________________________________________________________________
NAME OF SCHOOL:
_____________________________________________________________________________________
Submit the following upon filing of application:
Fully accomplished Application Form in two (2)
copies
Two (2) identical recent 1 x 1 ID pictures
Non-refundable test fee P 100 for private school
students/Free for public school students
Recommendation of the PSHS Registrar/DOST or
PSTO Coordinator:
As per data above:
Approved:
[
]
Disapproved:
[
]
Reason/s for Disapproval:
_______________________________________
Copy of report card (SY 2014-2015)
If final grade in Science and/ or Math is below 85,
submit a certification or proof that the child
belongs to the upper 10% of the class
_______________________________________
Processed by:
DOST ________________
PSHS ________________
To be accomplished by the PSHS Cashier:
Mode of Payment:
[
[
] Cash
] Money Order
No. of Applicants:
__________ (for group filing)
Amount Paid:
_________________
No. of stamps issued: _______________
Series Number: ______________________
Payment Received by: ____________________
Date: _______________
Date: _________________________________
REMINDERS TO THE EXAMINEE:
1.
Be at your testing center on October 3, 2015 one (1) hour before your scheduled examination (either a.m. or p.m. as indicated in the exam permit).
2.
Present the Examination Permit and your school I.D. to the Proctor/ Room Examiner.
3.
Bring at least two sharpened #2 pencils, a good eraser and snacks.
4.
If you do not receive your examination permit two (2) weeks before the exam, you may visit or call the nearest PSHS Campus or call PSHSSAdmissions Office at telephone no. (02) 926-5701 or check at www.pshs.edu.ph.
5.
In case of emergency (e.g. adverse weather conditions, impassable roads due to floods and earth quake), the NCE may be postponed. You should call the PSHSS
Admissions Office or the nearest PSHS Campus or check www.pshs.edu.ph for announcements.
6.
You will be notified if you qualify to enroll at PSHS either by mail or you may also check results at www.pshs.edu.ph. You may also inquire from the nearest
PSHS Regional Campus or call PSHSS-Admissions Office, Tel. No.: (02) 926-5701.
Admissions Office
OED, PSHSS
