Practicum Application Form
Practicum Application Form
Practicum Application Form
1x1
CIVIL STATUS: ________ SEX:________ AGE: ____ HEIGHT: ____ WEIGHT: _______
SCHOOL: ______________________________________________________________
COURSE: ______________________________________________________________
ADDRESS: ______________________________________________________________
________________________________________________________________________________
PLEASE INDICATE BELOW IF YOU HAVE OTHER SUBJECT/S ASIDE FROM PRACTICUM:
__________________________________________________________
_______________________________________________________________________
NAME: _________________________________________________________
ADDRESS: ______________________________________________________
TELEPHONE NO: _________________________ CELLPHONE NO: __________________
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)
PERSONAL BACKGROUND
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
Located at
________________________________________________________________________________________________________________________________
(Address)
Has been granted permission by the school administrator to undergo On-The-Job-Training (OJT) at the
Name of Company: ___________________________________________________________________________
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.
______________________________
Signature over printed name of Trainee
_________________________________
_____________________________________ Name & Signature of Parent/Guardian
Name & Signature of School Representative