THE 39th SHIP FOR SOUTHEAST ASIAN YOUTH PROGRAM (SSEAYP) 2012 APPLICATION FORM FOR PARTICIPATING YOUTH

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REGION TO BE REPRESENTED:____________________
Surname: ____________________________________ Gender: [ M ] [ F ] Height: ______________ Passport-sized photo

First Name: ____________________________________

Middle Name: __________________ Weight: _________ Age:__________________ Nickname: ___________ Birthdate: _______________ Birthplace: ______________ Official Mailing Address: __________________________________________________ ____________________________________________Zip Code: _______________

Residence Address: _____________________________________________________ Tel. No. (landline/Area Code): _____________ Mobile No.:_____________________ Email Address: _______________________ Religion: ________________ Present Occupation/Position: ____________________ _______________________ Pls. Indicate date taken

Name of Office or school: ____________ Office or School Address:_______________ Years in the Present Work: ______________ Fathers Name: Mothers Name: No. of Brother/s No. of Sisterr/s Educational Background Elementary Secondary Tertiary Vocational Post Graduate Scholarship Grants Civil Status: _____________________ Occupation: Occupation: Course / Inclusive Dates Honors Received

Place of Birth: Place of Birth: Name of School/University

Donor

Inclusive Dates

Honors Received

Youth Organization/Youth Serving Organization Affiliations: Name of Organization Position

Years of Membership

Accomplishments

Special Skills or Talents: Food Restrictions: Dialect(s) or Foreign Language(s) Spoken: Do you have a passport already? Yes ____ No ____ If yes, what is the number __________________ Expiry Date _______________ If not, have you applied already? Yes ____ No ____ If yes what is the status of your application? _____________________________ Title of Seminar/Training Course Attended Inclusive Dates Allergies

No. of Hours

Conducted by

Previous Work Experience Name of Company Position Inclusive Dates Salary

Character References: Name

[not related to you within the third degree of consanguinity] Occupation Address and Telephone No.

Please fill up form legibly

Not for Sale

All facts and data given in this information sheet will be treated with utmost confidentiality Please name any SSEAYP Alumni you know Relationship

Have you previously applied for SSEAYP? No Yes How did you know about the program? Newspaper: _____ Radio: ______ Magazine: _____ TV Ads: ______

How many times? Have you been a participant of any NYC International Exchange Program? [ ] No [ ] Yes If yes, please indicate the Program, year and source of fund

NYC Personnel: ________________________________ (Name of NYC personnel) Others [pls. Indicate]: ____________________________ Have you rendered voluntary service for the NYC? ? [ ] No

[ ] Yes

If yes, please state nature of service and how long [ ] Yes If yes, please indicate the program(s) and year.

Have you been involved with any NYC local program or activity? [ ] No

If no, are you willing to enter into a MOA with NYC to render voluntary work for its programs and activities? Have you joined or attended any SSEAYP activities? [ ] No [ ] Yes If yes, please indicate Have you availed of any program or scholarship grant offered by the Japanese government? [ ] No Have you attended any seminar, conference or trainings abroad? [ ] No [ ] Yes If yes, please indicate the program and year

[ ] Yes If yes, please indicate the program and year [ ] No [ ] Yes If yes, please indicate details [ ] No [ ] Yes

Do you anticipate to take part in any program, conference, board/bar exams or scholarships this year?

Are you on a scholarship granted by the Department of Science and Technology (DOST) and/or any other government agencies? If yes, please indicate Have you ever been convicted of any crime involving moral turpitude? [ ] No Do you have any pending civil and administrative case? [ ] No [ ] Yes [ ] Yes

If yes, please indicate the nature and status

f yes, please indicate the nature and status (you will be required to present clearance). [ ] No

Do you have any physical disability? [ ] Yes, please specify _____________________________ SWORN STATEMENT

I hereby certify upon my honor that all facts and information indicated herein are true and correct to the best of my knowledge. I further declare that any information given by me that is untrue may constitute a ground for expulsion in the SSEAYP and prosecution for perjury. Further, I subscribe and agree that the National Youth Commission has the sole prerogative to select, reclassify and nominate the delegates to the Ship for Southeast Asian Youth Program [SSEAYP], and its decision is final and executory. And if chosen, I will join the activities of the program such as Pre-departure training (July 16-25), pre-departure activities (S), cruise (O) and post-program evaluation (D). IN WITNESS hereof, I am executing and signing this statement voluntarily without compulsion. _____________________________ Signature

Res. Cert. Number: ____________________ Date and Place Issued: _________________ Qualifications:

Date accomplished:______________
8. must have a strong background of Philippine history, geography, culture and arts 9. must be knowledgeable on current issues about the Philippines, Japan and the other ASEAN countries 10. preferably first time international traveler and or must not have been a

1.
2012. 2. 3. 4.

Filipino citizen, single, must be between 18-30 years old as of April 1,

Of good moral character physically and mentally fit to travel must be residing at the place of representation for at least six (6) months at the time of submission a. if not employed or not studying, must be residing in the region to be represented for at least two (2) years immediately preceding from the date of application; b. If employed, the applicant must be working in the region to be represented for at least six (6) months immediately preceding from the date of application; 5. If a student, the applicant must be studying in the region to be represented for at least six (6) months immediately preceding from the date of application; if at the time of application, the applicant has less than six (6) months of stay in the workplace, school or residence, the Paper Screening Committee reserves the right to determine the applicants regional representation 6. If a student wishes to apply to represent a particular region, he/she must present a certification duly signed by the head of the organization or organizer that the applicant is actively participating in the regions activities for at least six (6) months immediately preceding from the date of application; 7. Must have served the youth sector as an active officer or member of a youth or youth serving organization for at least two (2) years immediately preceding the date of application

a. grantee or recipient of any NYC-coordinated international program, which round-trip airfare, food and accommodation were borne by the organizer/s, at least two (2) years immediately preceding from the date of application; b. grantee or recipient of any NYC-coordinated international program, which round-trip airfare was shouldered by the participants, at least one (1) year immediately preceding from the date of application
11. Must be willing to be an NYC volunteer after the program; and 12. Must be willing to take a leave of absence from school or work and complete all trainings and activities before, during and after the program:

Pre-departure Training Pre-departure Activities Cruise Post-Program Evaluation

July 16-25, 2012 Sept. 22-Oct. 22, 2012 Oct. 23-Dec. 13, 2012 Dec. 14-16, 2012

Requirements: [ Please submit only the required documents]

1. 2. 3.

One (1) copy of application form with passport sized photo. Photo should have a white background, original and not scanned. One (1) of the applicants resume (maximum of 3 pages only; no other attachments)

Passport must be valid until April 25, 2012

One (1) original copy of the Certificate of Residency issued by the Punong Barangay where the applicant is residing NYC AREA OFFICES LUZON VISAYAS Room 15, Hotel Legarda Ground Floor 5/F B. F. Building 2/F Marell Building No. 12, Legarda Road, Naga City Youth Center N. Escario St., Tiano-Gomez St. Baguio City Bldg. Cebu City Cagayan de Oro City Tel. No. 074-6190511 Taal Ave., Magsaysay Tel. No. 032-2689531 Tel. No. 088-8575895 Mr. Armando Angeles Jr. Naga City Ms Rhenelyn Dadulo Mr. Eddie Cuaresma Tel. No. 054-4730435 Ms. Nydia Paladan NOTE:

MINDANAO 3/F Atilano Bldg., Veterans Ave., Zamboanga City Tel. No. 062-9924851 Mr. Raymond Domingo

Davao Area Office, Old Bldg. ARDS Room, DSWD, Field Office IX, R. Magsaysay Ave., cor. D. Suazo St., Davao City Mr. Julius Gutierrez

Non-extendible deadline for submission of application form is 5:00 oclock pm on April 13, 2012. The National Youth Commission reserves the right and prerogative to exclude applicants who will not meet the minimum requirements of the Program. Lack or non-compliance of any of the above stated requirements will mean automatic disqualification without notice. Mail or hand carry your application to Ms. Marielou A. Chua, National Youth Commission, 4th Flr., Bookman Building, 373 Quezon Avenue, Quezon City.

Telephone No. 02-4162833. Application form with the requirements may be submitted through sseayp39@nyc.gov.ph on or before April 13, 2012. Please fill up the form legibly