THE 40th SHIP FOR SOUTHEAST ASIAN YOUTH PROGRAM (SSEAYP) 2013 APPLICATION FORM FOR PARTICIPATING YOUTH

(PY)
REGION TO BE REPRESENTED:____________________
Surname: ____________________________________ Gender: [ M ] [ F ] Height: ______________ Passp !"#s$%&' p( "

First Name: ____________________________________

Middle Name: __________________ Weight: _________ Age:__________________ Nickname: ___________ Birthdate: _______________ Birthplace: ______________ O icial Mailing Address: __________________________________________________ ____________________________________________!ip "#de: _______________

$esidence Address: _____________________________________________________ %el& N#& 'landline(Area "#de): _____________ M#*ile N#&:_____________________ +mail Address: _______________________ $eligi#n: ________________ ,resent Occupati#n(,#siti#n: ____________________ _______________________ P)s* I+'$,a"& 'a"& "a-&+

Name # O ice #r sch##l: ____________ O ice #r Sch##l Address:_______________ -ears in the ,resent W#rk: ______________ "i.il Status: _____________________ Father/s Name: ,lace # Birth: Occupati#n: M#ther/s Name: ,lace # Birth: Occupati#n: N#& # Br#ther(s N#& # Sisterr(s +ducati#nal Backgr#und Name # Sch##l(0ni.ersit1 "#urse ( 2nclusi.e 3ates +lementar1 Sec#ndar1 %ertiar1 4#cati#nal ,#st Graduate Sch#larship Grants 3#n#r 2nclusi.e 3ates

H#n#rs $ecei.ed

H#n#rs $ecei.ed

-#uth Organi5ati#n(-#uth Ser.ing Organi5ati#n A iliati#ns: Name # Organi5ati#n ,#siti#n

-ears # Mem*ership

Acc#mplishments

Special Skills #r %alents: F##d $estricti#ns: 3ialect's) #r F#reign 6anguage's) Sp#ken: 3# 1#u ha.e a passp#rt alread17 -es ____ N# ____ 2 1es8 9hat is the num*er __________________ +:pir1 3ate _______________ 2 n#t8 ha.e 1#u applied alread17 -es ____ N# ____ 2 1es 9hat is the status # 1#ur applicati#n7 _____________________________ %itle # Seminar(%raining "#urse Attended 2nclusi.e 3ates Allergies

N#& # H#urs

"#nducted *1

,re.i#us W#rk +:perience Name # "#mpan1 ,#siti#n 2nclusi.e 3ates Salar1

"haracter $e erences: Name

[n#t related t# 1#u 9ithin the third degree # c#nsanguinit1] Occupati#n Address and %eleph#ne N#&

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All facts and data gi !n in this inf"#$ati"n sh!!t %ill &! t#!at!d %ith 't$"st c"nfid!ntialit( ,lease name an1 SS+A-, Alumni 1#u kn#9 $elati#nship

Ha.e 1#u pre.i#usl1 applied #r SS+A-,7 N# -es H#9 did 1#u kn#9 a*#ut the pr#gram7 Ne9spaper: _____ $adi#: ______ Maga5ine: _____ %4 Ads: ______

H#9 man1 times7 Ha.e 1#u *een a participant # an1 N-" 2nternati#nal +:change ,r#gram7 [ ] N# [ ] -es 2 1es8 please indicate the ,r#gram8 1ear and s#urce # und

N-" ,ers#nnel: ________________________________ 'Name # N-" pers#nnel) Others [pls& 2ndicate]: ____________________________ Ha.e 1#u rendered .#luntar1 ser.ice #r the N-"7 7 [ ] N#

[ ] -es

2 1es8 please state nature # ser.ice and h#9 l#ng [ ] -es 2 1es8 please indicate the pr#gram's) and 1ear&

Ha.e 1#u *een in.#l.ed 9ith an1 N-" l#cal pr#gram #r acti.it17 [ ] N#

2 n#8 are 1#u 9illing t# enter int# a MOA 9ith N-" t# render .#luntar1 9#rk #r its pr#grams and acti.ities7 Ha.e 1#u ;#ined #r attended an1 SS+A-, acti.ities7 [ ] N# [ ] -es 2 1es8 please indicate Ha.e 1#u a.ailed # an1 pr#gram #r sch#larship grant # ered *1 the <apanese g#.ernment7 [ ] N# Ha.e 1#u attended an1 seminar8 c#n erence #r trainings a*r#ad7 [ ] N# [ ] -es 2 1es8 please indicate the pr#gram and 1ear

[ ] -es 2 1es8 please indicate the pr#gram and 1ear [ ] N# [ ] -es 2 1es8 please indicate details [ ] N# [ ] -es

3# 1#u anticipate t# take part in an1 pr#gram8 c#n erence8 *#ard(*ar e:ams #r sch#larships this 1ear7

Are 1#u #n a sch#larship granted *1 the 3epartment # Science and %echn#l#g1 '3OS%) and(#r an1 #ther g#.ernment agencies7 2 1es8 please indicate Ha.e 1#u e.er *een c#n.icted # an1 crime in.#l.ing m#ral turpitude7 [ ] N# 3# 1#u ha.e an1 pending ci.il and administrati.e case7 [ ] N# [ ] -es [ ] -es

2 1es8 please indicate the nature and status

1es8 please indicate the nature and status '1#u 9ill *e re=uired t# present clearance)& [ ] N#

3# 1#u ha.e an1 ph1sical disa*ilit17 [ ] -es8 please speci 1 _____________________________ S.ORN STATEMENT

2 here*1 certi 1 up#n m1 h#n#r that all acts and in #rmati#n indicated herein are true and c#rrect t# the *est # m1 kn#9ledge& 2 urther declare that an1 in #rmati#n gi.en *1 me that is untrue ma1 c#nstitute a gr#und #r e:pulsi#n in the SS+A-, and pr#secuti#n #r per;ur1& Further8 2 su*scri*e and agree that the Nati#nal -#uth "#mmissi#n has the s#le prer#gati.e t# select8 reclassi 1 and n#minate the delegates t# the Ship #r S#utheast Asian -#uth ,r#gram [SS+A-,]8 and its decisi#n is inal and e:ecut#r1& And i ch#sen8 2 9ill ;#in the acti.ities # the pr#gram such as ,re> departure training '<ul1 ?@>AB)8 pre>departure acti.ities 'Sept& AC>Oct& AD)8 cruise 'Oct&AC>3ec&?@) and p#st>pr#gram e.aluati#n '3ec&?D>?E)& %he undersigned e:pressl1 auth#ri5es the Nati#nal -#uth "#mmissi#n #r its representati.es t# use8 share and pr#cess pers#nal in #rmati#n that 2 ha.e pr#.ided8 shared #r declared in this #rm(d#cument(site #r an1 la9 ul purp#se& 2N W2%N+SS here# 8 2 am e:ecuting and signing this statement .#luntaril1 9ith#ut c#mpulsi#n& _____________________________ Signature $es& "ert& Num*er: ____________________ 3ate and ,lace 2ssued: _________________ /0a)$1$,a"$ +s:
?& AG?F& A& F& H& Be #re the date set #r the su*missi#n # applicati#n8 must n#t ha.e *een charged *e #re the pr#secuti#n/s # ice #r c#n.icted # a crime in.#l.ing m#ral turpitude ph1sicall1 and mentall1 it t# tra.el must *e residing at the place # representati#n #r at least si: '@) m#nths at the time # applicati#n a& i n#t empl#1ed #r n#r stud1ing8 must *e residing in the regi#n t# *e represented #r at least t9# 'A) 1ears immediatel1 preceding the date # applicati#nI *& 2 empl#1ed8 the applicant must *e 9#rking in the regi#n t# *e represented #r at least si: '@) m#nths immediatel1 preceding the date # applicati#nI 2 a student8 the applicant must *e stud1ing in the regi#n t# *e represented #r at least si: '@) m#nths immediatel1 preceding the date # applicati#nI i at the time # applicati#n8 the applicant has less than si: '@) m#nths # sta1 in the 9#rkplace8 sch##l #r residence8 the ,aper Screening "#mmittee reser.es the right t# determine the applicant/s regi#nal representati#n 2 a student 9ishes t# appl1 t# represent a particular regi#n8 he(she must present a certi icati#n dul1 signed *1 the head # the #rgani5ati#n that the applicant is acti.el1 participating in the regi#n/s 1#uth>related acti.ities #r at least si: '@) m#nths immediatel1 preceding the date # applicati#nI Must ha.e ser.ed the 1#uth sect#r as an acti.e # icer #r mem*er # a 1#uth #r 1#uth ser.ing #rgani5ati#n #r at least t9# 'A) 1ears immediatel1 preceding the date # applicati#n Filipin# citi5en8 single8 must *e *et9een ?C>FG 1ears #ld as # April ?8

3ate acc#mplished:______________
C& E& ?G& must ha.e a str#ng *ackgr#und in ,hilippine hist#r18 ge#graph18 culture and arts must *e kn#9ledgea*le #n current issues a*#ut the ,hilippines8 <apan and the #ther AS+AN c#untries pre era*l1 irst time internati#nal tra.eler and #r must n#t ha.e *een a

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grantee #r recipient # an1 N-">c##rdinated internati#nal pr#gram8 9herein r#und>trip air are8 ##d and acc#mm#dati#n 9ere *#rne *1 the #rgani5er(s8 at least t9# 'A) 1ears immediatel1 preceding the date # applicati#nI grantee #r recipient # an1 N-">c##rdinated internati#nal pr#gram8 9herein r#und>trip air are 9as sh#uldered *1 the participants8 at least #ne '?) 1ear immediatel1 preceding the date # applicati#n

B&

Must *e 9illing t# *e an N-" .#lunteer a ter the pr#gramI and Must *e 9illing t# take a lea.e # a*sence r#m sch##l #r 9#rk and c#mplete all trainings and acti.ities *e #re8 during and a ter the pr#gram:

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P!&#'&pa!"0!& T!a$+$+2 P!&#'&pa!"0!& A,"$8$"$&s C!0$s& P s"#P! 2!a; E8a)0a"$ +

30)4 15#267 2013 S&p"* 29 # O,"* 2:7 2013 O,"* 29 # D&,* 157 2013 D&,* 1:#1<7 2013

?F& Must *e 9illing t# cra t a p#lic1 paper t# *e su*mitted 9ithin #ne hundred '?GG) da1s r#m end # the pr#gram&

D&

R&=0$!&;&+"s: [ ,lease su*mit #nl1 the re=uired d#cuments] ?& One '?) c#p1 # applicati#n #rm 9ith passp#rt si5ed ph#t#& ,h#t# sh#uld ha.e a 9hite *ackgr#und8 #riginal and n#t scanned& A& One '?) c#p1 # the applicant/s resume 'ma:imum # F pages #nl1I n# #ther attachments) F& One '?) #riginal c#p1 # the "erti icate # $esidenc1 issued *1 the ,un#ng Baranga1 9here the applicant is residing H& One '?) #riginal c#p1 # a certi icati#n r#m the #rgani5ati#n that the applicant is an acti.e mem*er #r at least t9# 'A) 1ears immediatel1 preceding the applicati#n peri#d& ,assp#rt must *e .alid until April AB8 AG?F

NOTE: N +#&>"&+'$?)& deadline #r su*missi#n # applicati#n #rm is B:GG #/cl#ck pm #n April ?A8 AG?F& %he Nati#nal -#uth "#mmissi#n reser.es the right and prer#gati.e t# e:clude applicants 9h# 9ill n#t meet the minimum re=uirements # the ,r#gram& 6ack #r n#n>c#mpliance # an1 # the a*#.e stated re=uirements 9ill mean aut#matic dis=uali icati#n 9ith#ut n#tice&

)U*ON $##m ?B8 H#tel 6egarda Gr#und Fl##r N#& ?A8 6egarda $#ad8 Naga "it1 -#uth Bagui# "it1 "enter Bldg& %el& N#& GDH>@?EGB?? %aal A.e&8 Magsa1sa1 Mr& Armand# Angeles <r& Naga "it1

Mail #r hand carr1 1#ur applicati#n t# Ms& Mariel#u A& "hua8 Nati#nal -#uth "#mmissi#n8 Hth Flr&8 B##kman Building8 FDF Jue5#n A.enue8 Jue5#n "it1& %eleph#ne N#& GA>H?@ACFF& Applicati#n #rm 9ith the re=uirements ma1 *e su*mitted thr#ugh ssea1pHGKn1c&g#.&ph #n #r *e #re April ?A8 AG?F& N-" A$+A OFF2"+S +ISAYAS MIN,ANAO B(F B& F& Building A(F Marell Building F(F Atilan# Bldg&8 3a.a# Area O ice8 Old N& +scari# St&8 %ian#>G#me5 St& 4eterans A.e&8 Bldg& A$3S $##m8 "e*u "it1 "aga1an de Or# "it1 !am*#anga "it1 3SW38 Field O ice 2L8 %el& N#& GFA>A@CEBF? %el& N#& GCC>CBDBCEB %el& N#& G@A>EEAHCB? $& Magsa1sa1 A.e&8 c#r& Ms $henel1n 3adul# Mr& +ddie "uaresma Mr& $a1m#nd 3#ming# 3& Sua5# St&8 3a.a# "it1

%el& N#& GBH>HDFGHFB Ms& N1dia ,aladan ,lease ill up the #rm legi*l1

Mr& <ulius Gutierre5