Republic of the Philippines
Department of Science and Technology
PHILIPPINE COUNCIL FOR INDUSTRY, ENERGY AND EMERGING TECHNOLOGY RESEARCH AND DEVELOPMENT (PCIEERD)
Learning at Scale Vol. I: Data Science Track
APPLICATION FORM
Name of Applicant
Occupation
Programming Language(s) Used
Email Address Contact No.
1 Trainee Information
A. PERSONAL INFORMATION
Gender Male Female Age
Birthdate Month Date Year
Birthplace Citizenship Home Address
B. EDUCATIONAL INFORMATION Highest degree obtained
University/address Inclusive dates Honors received, if any
C. EMPLOYMENT DETAILS (if any) Current designation
Inclusive dates Company Name Office Address
Brief description of duties and responsibilities (use additional sheet, if necessary)
2 List of Relevant Trainings Attended
Name of Training Year Taken
*Note: Please attach one (1) copy of each proof stated.
This is to signify my interest to apply in the training entitled “Learning at Scale Vol. I: Data Science Track”
and participate/complete the training on the agreed timeframe once accepted in the program. Furthermore, I attest that I am aware of the six (6) month service obligation through service in any private or government institution in the Philippines or through engagement in S&T entrepreneurial activities in the country. Lastly, I hereby certify that the above information is true and correct to the best of my knowledge.
Signature over printed name Date
Endorsed by:
Signature over printed name (Supervisor, Professor)
To be filled up by PCIEERD DOCUMENTARY REQUIREMENTS
Accomplished application form Certified true copy of transcript of records, diploma, if graduate Endorsement of Dean, if undergraduate
Curriculum Vitae (CV) Certificate of employment (if applicable) Copy of birth certificate or passport Certificates/ Proof of related trainings attended
