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