(Form 3)

College of Engineering
XAVIER UNIVERSITY (Ateneo de Cagayan)
Cagayan de Oro City

TRAINEE INFORMATION SHEET

PERSONAL DATA:
NAME ___________________________________________ SEX ___________ AGE_______
DATE OF BIRTH _____________________ PLACE OF BIRTH ________________________
CIVIL STATUS ______________ NAME OF SPOUSE, if married ______________________
CITIZENSHIP _________________ RELIGION _____________________________________
CITY ADDRESS ______________________________________________________________
FATHER __________________________ MOTHER _________________________________
HOME/MAILING ADDRESS ____________________________________________________
CELLPHONE/FAX NUMBER (S) ______________________EMAIL ____________________
EDUCATIONAL ATTAINMENT:
LEVEL NAME & ADDRESS OF SCHOOL INCLUSIVE DIPLOMA/DEGREE
DATES EARNED/YEAR LEVEL
ELEMENTAR
Y
SECONDARY
COLLEGE

SPECIAL STUDIES/SKILLS/TRAINING: ________________________________________

______________________________________________________________________________
______________________________________________________________________________
SCHOLASTIC ACHIEVEMENT: _______________________________________________
MEMBERSHIP IN ORGANIZATIONS: __________________________________________
_____________________________________________________________________________
IN CASE OF EMERGENCY, PLEASE NOTIFY:
NAME_________________________________________ RELATION ___________________________
ADDRESS ___________________________________________________________________________
CELLPHONE/FAX NUMBERS/EMAIL ___________________________________________________
(Form 3)

OJT APPLICANT’S SIGNATURE _____________________DATE APPLIED __________________

Attachment ( XU-Engineering Office Use Only)

NAME OF OJT PARTICIPANT

________________________________________________
COURSE & YEAR
_________________________________________________________
NAME OF COMPANY
_________________________________________________________

Please answer the following questions truthfully. Your answers will be treated with
utmost confidentiality.

1.Are you pregnant? [] Yes [] No [] n/a

If yes, please indicate the number of months. ______________________

2.Do you suffer from any illness such as epilepsy, tuberculosis, hypertension or
heart condition? [] Yes [] No
Others, please specify. _____________________________________________

3.Are presently taking prescription medicines?

[] Yes [] No
If Yes, please specify the kind of medicine and indicate for what treatment.
_______________________________________________________________
_______________________________________________________________

4.Is there any special medical attention that the College should be aware of?
[] Yes [] No
If Yes, please specify. ______________________________________________
______________________________________________

This is to certify that the undersigned has provided only the true and correct
information as deemed necessary.

___________________________
Signature Over Printed Name