Republic of the Philippines

CENTRAL BICOL STATE UNIVERSITY OF AGRICULTURE

San Jose, Pili, Camarines Sur 4418
Website: www.cbsua.edu.ph
Email Address: op@cbsua.edu.ph
Trunkline: (054) 871-5531-33 local 101

College: College of Engineering and Food Sciences

Department: Department of Agricultural and Biosystems Engineering

CONSENT OF PARENT OR GUARDIAN

I, MARIA FELICIANA BENITA M ELORETA , of legal age, a resident of Zone 6, San

Rafael, Tigaon, Camarines Sur and parent/guardian of Mr. RALPH VINCENT M ELORETA
, do hereby give him/her full consent to conduct her Industry Immersion Program (IIP) on
June 13, 2022 to July 8, 2022 at ______________________________________.
I understand that my son/daughter will be guided by the rules on student conduct as if
he/she were in the Central Bicol State University of Agriculture campus and also by the
pertinent rules and regulations of the agency he/she will be conducting his/her Industry
Immersion
I hereby agree that I will not hold the faculty concerned, the university and the agency
liable for any untoward incident that may happen during the duration of the Industry
Immersion Program (IIP) which are beyond their control.
IN WITNESS HEREOF, I have unto signed this parental consent this ________ day of
____________, at ____________________________________________________.

MARIA FELICIANA BENITA M ELORETA

Name and Signature of Parent/Guardian

Witness: __________________________________________________________________

SUBSCRIBED AND SWORN to me this _______ day of __________________, 20___ in the

Municipality of ________________________ Province of ____________________________.

The parent/guardian exhibited to me his/her residence Certificate No. _________ Issued

_____________________on ______________________.

____________________________________
Notary Public

Doc. No. ____________ Until: ____________

Page No. ___________ TIN: _____________

OSA-FR-011c Rev.:0
Effectivity Date: July 14, 2021 Page 1 of 1