F-OJT-17L

2X2
PICTURE

K- 12 WORK IMMERSION PERSONAL DATA SHEET

STUDENT INFORMATION

Name: _______________________________ Student No.: _____________ Track: ____________

Section: _________________ Work Immersion Adviser: __________________________________

Address: _________________________________________________________________________

Contact No. (Landline): ____________________ (Mobile):_________________________________

Person to notify in case of emergency: ________________________________________________

Relationship: _________________________ Contact No.: _________________________________

COMPANY INFORMATION

Name of Company: ________________________________ Contact No.: _____________________

Address of Company: _______________________________________________________________
Company Contact Person: ____________________________ Position: ______________________

CONFORME:

By signing below, I hereby voluntarily waive any and all rights I may have to privacy and/or confidentiality pertaining to the
above-mentioned purposes insofar as the information is released solely the authorized persons in accordance thereto.

_______________________________
Signature over Printed Name

_______________________
Date Signed

Revision No.: 2 Address: Governor Feliciano Leviste Road, Lipa City 4217, Batangas, Philippines
Issue Date: October 2, 2018 Telephone Numbers: +63 43 757 5277
Revision Date: September 12, 2018 Website: www.ub.edu.ph