Reference No.: BatStateU-FO-OJT-02 Effectivity Date: January 3, 2017 Revision No.

: 00

“1X1”
STUDENT TRAINEE’S PERSONAL HISTORY STATEMENT
PICTURE

Student Information
LAST NAME:
FIRST NAME: GLENMARC MIDDLE NAME: DALUZ
DEQUINA
AGE: 21YRS OLD SEX MALE FEMALE
HEIGHT: 168CM WEIGHT: 82KG COMPLEXION: Brown
DISABILITY (IF ANY): N/A

BIRTHDATE: BIRTHPLACE: POBLACION 1, CALATAGAN, BATANGAS

09 - 22 - 00
CITIZENSHIP: Filipino CIVIL STATUS: SINGLE
PRESENT ADDRESS: POBLACION 1, CALATAGAN, BATANGAS TEL NO./CP NO.: 0949-112-7576
PROVINCIAL ADDRESS: CALATAGAN, BATANGAS TEL NO./CP NO.:

Family Background (if parents are deceased, give data for the nearest relative and indicate relationship to applicant)

FATHER’S NAME: GLENN B. DEQUINA OCCUPATION: SELF-EMPLOYED

MOTHER’S NAME: MARICEL D. DEQUINA OCCUPATION: SELF-EMPLOYED
ADDRESS OF PARENTS: POBLACION 1, CALATAGAN, TEL. NO./CP NO: 0948-453-0295
BATANGAS
GUARDIAN’S NAME: MARICEL D. DEQUINA TEL. NO.: 09484530295
SCHOOL INFORMATION
PROGRAM: BS CRIMINOLOGY YEAR LEVEL: 3RD YEAR
MAJOR: N/A LENGTH OF PROGRAM:
SCHOOL ADDRESS: BRGY. BUCANA,
DEPARTMENT: COLLEGE OF ARTS AND SCIENCES
NASUGBU, BATANGAS
OJT COORDINATOR: MS. ELSIE MONTEALEGRE TEL. NO./ CP NO.:
OJT ASST. TEL. NO.:
DEAN: DR. MARIA LUISA A. VALDEZ TEL. NO.:
In case of emergency, notify
NAME: MARICEL D. DEQUINA RELATIONSHIP: MOTHER
ADDRESS: POBLACION 1, CALATAGAN, BATANGAS TEL. NO./ CP NO.: 0948-453-0295

I hereby certify that the foregoing answers are true and correct to the best to my knowledge, belief and ability.

Signed at: ___________________________________ Date: _______________________________

Applicant’s Signature over Printed Name