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10 Student Trainees Personal History Statement

This document is a personal history statement and application for a practicum/internship program. It requests basic student information such as name, birthdate, address, family background, school details including program and year level, and host training establishment details including company address and contact person. It requires the student's signature to certify the information as well as endorsements from the program chairperson, department head, and college dean to approve the application.

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970 views2 pages

10 Student Trainees Personal History Statement

This document is a personal history statement and application for a practicum/internship program. It requests basic student information such as name, birthdate, address, family background, school details including program and year level, and host training establishment details including company address and contact person. It requires the student's signature to certify the information as well as endorsements from the program chairperson, department head, and college dean to approve the application.

Uploaded by

Emmanuel
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Southern Luzon State University

Office of the Vice President for Academic Affairs


Office of Student Affairs and Services – Career and Job Placement

STUDENT TRAINEE’S PERSONAL HISTORY STATEMENT


(APPLICATION FOR PRACTICUM/INTERNSHIP PROGRAM) 1X1
PICTURE

I. Student Information
Name: ________________________________________________________________
Last First Middle
Birthday:_________________________Birth Place: ____________________________
Age: _____ Sex: ______ Height: ______ Weight: ______ Complexion: _____________
Disability (If any): _________________________
Citizenship:___________________________ Civil Status: _______________________
Present Address: ____________________________Contact Number: _____________
Provincial Address: __________________________ Contact Number: _____________

II. Family Background


Father’s Name: ___________________________ Occupation: ___________________
Mother’s Name: ___________________________ Occupation: ___________________
Address of Parents: _____________________________________________________
Contact Number of Parents: ______________________________________________
Guardian’s Name: ___________________________Contact Number: ______________

III. School Information


College & Program: ______________________________ Year Level: _____________
Length of Practicum/Internship: _____________________
SIPP Coordinator: ____________________________ Contact Number: ____________
Dean: ______________________________________ Contact Number: ____________

IV. Host Training Establishment (HTE) Information


Partner HTE: __________________________________________________________
Company Address: _____________________________________________________
Email Address: ___________________________ Contact Number: _______________
Contact Person: ______________________________________________________
Designation: _____________________________ Contact Number: _______________

In case of emergency, notify


Name: __________________________________ Relationship: __________________
Address: ________________________________ Contact Number: _______________

I hereby certify that the foregoing answers are true and correct to the best of my
knowledge, belief and ability.

Signed at: _____________________________ Date: __________________________

________________________________
Signature over Printed Name of Applicant

Endorsed by:
__________________________ __________________________
Signature over Printed Name of Signature over Printed Name of
Program Chairperson Department Head

Approved by:
_________________________
Signature over Printed Name of
College Dean/Campus Director

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