APPLICATION FOR PRACTICE TEACHING

PANGASINAN STATE UNIVERSITY

San Carlos City Campus

CAMPUS SAN CARLOS CITY CAMPUS ADDRESS Roxas Blvd., San Carlos City, Pangasinan
PRACTICE TEACHING COORDINATOR Creleah R. Menor, MAEd CONTACT NUMBER O9496057481
ACADEMIC YEAR 2021-2022 PERIOD OF PRACTICE TEACHING School Year 2021-2022
A. PERSONAL PROFILE

NAME FERNANDEZ JENINA A.

Last Name First Name M. I.

COURSE AND SPECIALIZATION BACHELOR OF SECONDARY EDUCATION MAJOR IN SOCIAL

STUDIES
STUDENT NUMBER 18-SC-6021

HOME ADDRESS BRGY. SAPINIT, SAN CARLOS CITY, PANGASINAN

LOCAL ADDRESS BRGY. SAPINIT, SAN CARLOS CITY, PANGASINAN

MOBILE NUMBER 09638592831 EMAIL ADDRESS fernandezjet6338@gmail.com

RECEIPT NO. (ST Fee)

TYPE OF COMMUNITY IN WHICH YOU HAVE LIVED THE MAJOR PART OF YOUR LIFE:

 Barrio/ Sitio Town/ Poblacion City

BIRTHDAY February 7, 2000 CIVIL STATUS SINGLE

HEIGHT 5’1 WEIGHT 40kg.
NAME OF FATHER JERRY B. FERNANDEZ OCCUPATION
Decreased(+)
HIGHEST EDUCATIONAL ATTAINMENT
Elementary High school College

NAME OF MOTHER GINA A. FERNANDEZ OCCUPATION BRGY. HEALTH WORKER

HIGHEST EDUCATIONAL ATTAINMENT
Elementary High school College

ANNUAL INCOME OF PARENTS 3,000 ESTIMATED MONTHLY ALLOWANCE LESS THAN 3,000
NUMBER OF SIBLINGS NONE POSITION IN THE FAMILY ONLY CHILD
NAME OF SPOUSE

FERNANDEZ, JENINA ALCANTARA

Practice Teacher’s Signature over Printed Name
Date: February 17,2022

C. MEDICAL AND PSYCHOLOGICAL RESULTS (Please submit or attach a copy of the certification/results)

Medical Certificate Vaccination Card or Certificate

D. ACTION TAKEN

Qualified for Practice Teaching Not qualified for Practice Teaching

Reason/s for disapproval:
not physically fit
other reasons (pls. specify):

EVALUATED BY: NOTED BY: APPROVED:

Coordinator, Practice Teaching Chairman, Professional Education Department Dean, College of Teacher Education

Date: Date: Date: