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PRACTICUM APPLICATION FORM
STUDENT’S NAME: __________________________________________________________
HOME ADDRESS: ____________________________________________________________
TELEPHONE NUMBER: _______________________________________________________
CELLPHONE NUMBER: _______________________________________________________
CIVIL STATUS: ________ SEX:________ AGE: ____ HEIGHT: ____ WEIGHT: _______
SCHOOL: ______________________________________________________________
COURSE: ______________________________________________________________
ADDRESS: ______________________________________________________________
TELEPHONE NUMBER: __________________ FAX NO: __________________
IN CASE OF EMERGENCY, PLEASE NOTIFY:
NAME: ________________________________________ RELATION: ______________
HOME ADDRESS: _______________________________________________________
TELEPHONE NO: ___________________________ CELLPHONE NO: _______________
OFFICE ADDRESS: ____________________________________________________________
PLEASE DECLARE IF UNDERGOING ANY SPECIAL TREATMENT FOR ANY AILMENTS
LIKE ASTHMA, DIABETIC, HIGBLOOD, ALLERGIES, ETC.
PLEASE SPECIFY: ______________________________________________________________
________________________________________________________________________________
PLEASE INDICATE BELOW IF YOU HAVE OTHER SUBJECT/S ASIDE FROM PRACTICUM:
__________________________________________________________
_______________________________________________________________________
AVAILABLE DAY AND TIME FOR PRACTICUM:
NAME: _________________________________________________________
ADDRESS: ______________________________________________________
TELEPHONE NO: _________________________ CELLPHONE NO: __________________
RESUME OF EDUCATIONAL EXPERIENCE/WORK EXPERIENCE
CAREER OBECTIVE: __________________________________________________________
EDUCATIONAL BACKGROUND
YEAR DEGREE EARNED NAME OF SCHOOL & ADDRESS HONOR RECEIVED
______ _____________ ___________________________ ________________
______ _____________ ___________________________ ________________
______ _____________ ___________________________ ________________
(NOTE: Arrange from college, high school and Elementary. Indicate any special awards, accomplishments achieved in the appropriate level)
WORK EXPERIENCE
YEAR POSITION COMPANY NAME & ADDRESS
______ _____________ ___________________________
______ _____________ ___________________________
______ _____________ ___________________________
(NOTE: a short description of your job may be included)
EXTRA CURRICULAR ACTIVITIES:
YEAR/DATE POSITION/ACTIVITIES ORGANIZATION
______ _____________ ___________________________
______ _____________ ___________________________
______ _____________ ___________________________
SEMINAR & TRAINING ATTENDED
YEAR/DATE TITLE CONDUCTED BY:
______ _____________ ___________________________
______ _____________ ___________________________
______ _____________ ___________________________
PERSONAL BACKGROUND
AGE: ________ SEX: _________ WEIGHT: ______ HEIGHT: ______
CIVIL STATUS: _________ RELIGION: ____________
REFERENCES
NAME POSITION COMPANY NAME & TELEPHONE NO
_______________ _____________ ___________________________
_______________ _____________ ___________________________
_______________ _____________ ___________________________
(NOTE: Maybe available upon request. If the student decides to include name of references, this format is suggested)
SIGNATURE:_______________ _________DATE:______________
TRAINEE –INDUSTRY AGREEMENT AND LIABILITY WAIVER
TO WHOM IT MAY CONCERN:
THIS IS TO CERTIFY that I, _______________________________________________________________
(Name of Trainee)
A____________________ ___________student___________________________________________________________
(Course & Year)
Located at
________________________________________________________________________________________________________________________________
(Address)
Has been granted permission by the school administrator to undergo On-The-Job-Training (OJT) at the
Name of Company: ___________________________________________________________________________
Address of the Company: _______________________________________________________________________
From: _________________ to: _____________________
FURTHER, I hereby voluntarily agree to undergo the said training in any industrial firm in order to acquire industrial
work experience with the following terms & conditions:
1. That I shall abide by the company’s rules and regulations and shall comply with the
imposed requirements for the On-the-Job-Training (OJT), otherwise I shall be excluded
from further participation
2. That there is no employer-employee relationship between company and me
3. That I shall be made answerable for all liabilities and damages to property of the company
or injury to the third party persons from my intentional or negligent while in the course of
my training
4. That the Company will not held liable for any injury/illness that may occur during the
training period that I shall not hold the company liable for payment of medical expenses
and treatment which may be needed in the event of such occurrence.
Signed on this: _________ day of ________, 2023 at ____________________________ City,
Philippines
______________________________
Signature over printed name of Trainee
With our consent and approval:
_________________________________
_____________________________________ Name & Signature of Parent/Guardian
Name & Signature of School Representative
