Republic of the Philippines

MARINDUQUE STATE COLLEGE

SCHOOL OF ENGINEERING
Tanza, Boac, Marinduque

SCHOOL OF ENGINEERING

Name of Student: _______________________________ Gender: _________________

Course, Year & Major: ___________________________ Mobile Phone No.__________________
Date of Birth: __________________________________ Email Address: ____________________
Address: _____________________________________________________________________________
Name of the Parents/Guardian to Contact in Case of emergency: ________________________________
Address of the Parent/Guardian: __________________________________________________________
Mobile Phone Number of the Parent/Guardian: ______________________________________________
Host Training Establishment: _____________________________________________________________
Address: _____________________________________________________________________________

CHECKLIST OF OJT REQUIREMENT

Complied
Specific Requirements Annexes (put check if Remarks
complied)
A. Students
1. Birth Certificate Tab A
2. Evaluation Checklist (issued by Registrar) Tab B
3. Medical Certificate Tab C
4. Notarized Parent’s/Guardian Consent Tab D
5. Training Contract Tab E
6. Certificate of Insurance Coverage Tab F
7. Official Registration Form Tab G

B. HTEs & HEIs

1. Memorandum of Agreement Tab H
2. Internship Plan Tab I
3. Certification that THE venue site s Tab J
inspected and found safe

Checked and Validated by:

_____________________
SIPP COORDINATOR

Reviewed and Endorsed by:

______________________
Dean