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Republic of the Philippines

President Ramon Magsaysay State University


Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

AN OUTCOMES BASED FLEXIBLE LEARNING COURSE SYLLABI


(References: CMO 75, S. 2017, R.A. 7227 & CMO No.77, S.2017, CMO No. 4, S.2020, RA 8972, University Faculty Manual, Student Manual, Registrar’s Manual
Board Approved PRMSU Strategic Framework for Flexible Teaching and Learning and other CMO’s of different programs offered in the university)

FACULTY INFORMATION AND SCHEDULE

Campus College College of Teacher Education

Program Semester & 1st Semester, S.Y. 2021-2022


School Year
Professor/ Class Schedule
Instructor
Information Consultation
Hours
I. VISION, MISSION, QUALITY POLICY, COLLEGE GOALS AND PROGRAM OBJECTIVES

University Vision The President Ramon Magsaysay State University shall be a College Goals
progressive learner-centered research university recognized in 1. Relate education to the larger historical, social, cultural and
the ASEAN Region in 2020. political processes;
2. Use wide range of teaching methodologies to effectively
facilitate learning in various types of environments;
3. Devise alternative teaching approaches for diverse
learners
4. Plan lessons with appropriate instructional materials to
effective delivery and assessment of learning outcomes
5. Build a strong character reflecting professional and ethical
standards; and
6. Grow in person and in profession through the pursuit of

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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

lifelong learning.
7. Attain above the national passing percentage rate of
Licensure Examination for teachers.

Bachelor of Secondary Education program


The President Ramon Magsaysay State University shall
primarily provide advance and higher professional, technical,  Demonstrate in deep understanding of scientific
University Program concepts and principles
special instructions in various disciplines; undertake research,
Mission Objectives  Apply scientific inquiry in teaching and learning
extension, and income generation programs for sustainable  Utilize effective science teaching and assessment
development of Zambales, the region, and the country. methods

The PRMSU values diversity and seeks talented students,


faculty, and staff from diverse backgrounds. The PRMSU does
not discriminate on the basis of race, color, sex, sexual
The President Ramon Magsaysay State University is committed orientation, gender identity, religion, creed, national, or ethnic
to continually strive for excellence in instruction, research, Non- origin, citizenship status, age, disability, veteran status or any
Quality Policy extension and production to strengthen global competitiveness Discrimination other legally protected class status in the administration of its
adhering to quality standards for the utmost satisfaction of its Statement admissions, financial aid, educational or athletic programs, or
valued customers. other University administered programs or in its employment
practices. Questions or complaints regarding this policy should
be directed to the Vice President of Academic and Student
Affairs and Director of Student Affairs, PRMSU, Iba, Zambales.
II. COURSE INFORMATION

Course Code Pen 3 Course Title INDIVIDUAL AND DUAL SPORTS


Semester and The course focuses on Individual and dual sports namely
1st Semester
Year Level Course ARNIS and BADMINTON. It gives information on the
1st Year
Offered Description history, development, facilities and equipment’s and
Credit Units 2 units lecture simple rules of the games.
Contact Hours 2 hours (Lecture) – 36 Hours Place of Course
General Education
per Week In the Program

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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

PEN 1 PHYSICAL FITNESS AND OUTDOOR


Pre-Requisite Co-Requisite
RECREATIONAL ACTIVITIES
Online Approach:
Access Device/s: Smartphone, Laptop, Desktop, Smart
TV or Tablet
Connection (Internet Bandwidth Minimum Requirement:
 2.0 Mbps up and down for single screen
Online Approach: Synchronous and Asynchronous  2.0 Mbps up 4.0 Mbps down for dual screen
 2.0 Mbps up 6.0 Mbps down for triple screen
This course is conducted virtually using  For screen sharing only: 150-300kbps
videoconferencing applications and Learning  For audio VoIP: 60-80kbps
Management System (LMS) Software Platforms:
 Facebook Messenger App
Modular Approach :  Zoom, Google Meet, Skype, Messenger Video-call
Course Delivery Course  Free LMS (Edmodo & Google Classroom)
This course is home-based learning approach through
Mode Requirement  University LMS
drop box system with the help of LGU-Barangay.
Learning Preparation:
 Any form of Multimedia Presentations
Limited or Full implementation of Face to Face
Classes: This course is conducted in school set-up Learners Initial Requirements for Online Approach:
classroom learning but it depends upon the  Basic knowledge in using Facebook-messenger,
instruction/guidelines from local government unit and Zoom and LMS Applications.
the Commission on Higher Education (if applicable).
Modular (Self Learning Module) Approach :
 Printed Self Learning Module
 Basic or Feature Phone for text and call only
 Drop Box
 Vehicle for transportation of SLM
Online Approach: Netiquette for Online Classroom:
Course
Announcements will be posted in the Messenger Group Course Etiquette During virtual classroom discussion, it is important to
Communication
Account/Chat box and via LMS on a regular basis. understand the rules of netiquette on how to interact
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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

with one another online. You can read more about the
Modular (Self Learning Module) Approach:
rules of netiquette at
Announcements will be given in a form of (http://www.albion.com/netiquette/index.html)
printed/hardcopy through Drop Box LGU-Barangay,
SMS Text and Phone call.
III. STUDENT OUTCOMES (INSTITUTIONAL, PROGRAM AND COURSE)

PRMSU PRMSU Graduate is expected to be an excellent: PROGRAM


GRADUATE EDUCATIONAL
ATTRIBUTES a. LEADER NOT APPLICABLE
OBJECTIVES
INSTITUTIONAL IILO 1 Strong network leader, who is committed,
(PEO)
morally upright, and responsible, and who
INTENDED
proactively governs in the specific field of
LEARNING specialization
OUTCOMES IILO 2 Visionary leader, who effectively manages and
PROGRAM When one has fully completed the BACHELOR OF
(IILOs) optimizes human capital toward sustainable
INTENDED ELEMENTARY EDUCATION Program, the students shall have
development
LEARNING the ability to:
PILO 1 Possess and exhibit moral and ethical standards
b.COMMUNICATOR OUTCOMES
as physical education students and sports and
IILO 3 Strong and effective communicator, who has (PILOs) AND fitness enthusiast and advocates.
the power to express himself/herself orally PERFORMANCE PILO 2 Possess healthy lifestyle for lifelong physical
and in writing, and other appropriate modes
INDICATORS fitness activities.
of expression PILO 3 Strong catalyst and proficient advocate in
IILO 4 Competitive and lifelong learner, whose (PIs)
propagating active healthy lifestyle and optimum
excellence in services towards local and global level of fitness.
needs (Mother College) PILO 4 Execute pedagogical knowledge and skills in
physical fitness and recreational outdoor activities
c. INNOVATOR in line with the global standards.
IILO 5 Research-oriented individual, who uses PILO 5 Possess optimum level of proficiency in
scientific process to create knowledge conducting research aimed at improvement of
necessary to address varied societal needs Physical Education, physical fitness and
towards inclusive growth and sustainable recreational outdoor activities towards continuous
development professional development.

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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

IILO 6 Critical thinker and problem solver, who is PILO 6 Demonstrate analytical and critical thinking skills
equipped in research methods and utilizes focused on developing new medium and
empirical evidence and scientific approach to pedagogy of learning.
knowledge creation and utilization through
knowledge transfer
By the end of the course, the students will be able to:

CILO 1 Trace the history of badminton and arnis;


CILO 2 Explain the importance of warm-up exercise;
COURSE CILO 3 Determine the benefits and demonstrate the proper
INTENDED procedure for flexibility exercise;
CILO 4 Identify the different basic skills and the facilities and
LEARNING
equipment needed in playing badminton and arnis;
OUTCOMES CILO 5 Familiarize oneself with basic rules and regulations in
(CILOs) playing badminton and arnis; and
CILO 6 Perform properly the different badminton and arnis
drills.

IV. COURSE CONTENT AND CONSTRUCTIVE ALIGNMENT

TOPIC DURAT TEACHING


STUDENT ASSESSMENT ONLINE/PRINTED
LEARNING ION/ LEARNING
PILOs CILOs TOPIC OUTLINE LEARNING TASKS REFERENCES
OUTCOMES WEEK ACTIVITIE
TIME
(TLOs) NO. S
TLO 1 General Orientation
Trace the brief history Mission/ Vision Lecture Website: www. rmtu.com
Week Quiz
1 of Arnis. General Information 2 hours Discussion
1. History Overview 1
https://
Discuss the nature of 2. Basic Concept in arnis phlconnect.ched.gov.ph/home

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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

the game.
https://www.youtube.com/
Analyze the channel/
development of the UCaimyyl8ttsaKTBmaB13hxQ?
game. app=desktop

https://www.youtube.com/
results?
app=desktop&sp=mAEA&search
_query=matti+san+juan

Physical Education 3(individual


and dual sports)
PNU Licensure Examination for
Teachers Handout
TLO 2 https://
Facilities and equipment WEEK Lecture phlconnect.ched.gov.ph/home
2,3 2 hours  Quiz
Identify the different in Arnis. 2 Discussion
facilities and https://www.youtube.com/

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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

channel/
UCaimyyl8ttsaKTBmaB13hxQ?
app=desktop

https://www.youtube.com/
results?
equipment’s in arnis. app=desktop&sp=mAEA&search
_query=matti+san+juan
Appreciate the
importance of Physical Education 3(individual
equipment’s in arnis. and dual sports)
PNU Licensure Examination for
Teachers Handout

Presas Remy A., MODERN ARNIS,


Modern Arnis Publishing Co.
520 Quezon Boulevard,
Manila, 1974

Presas Remy A., THE PRACTICAL


ART OF ESKRIMA, Modern Arnis
Publishing Co. 520
Quezon Boulevard Manila, 1980

4 TLO 3 Elements to become a Week 2 hours Lecture Quiz Physical Education 3(individual
Explain the good fighter 3 Discussion performance and dual sports)
importance of the demonstra
different elements. tion PNU Licensure Examination for
Preparing your body for
Teachers Handout
arnis.
Explain the 1. limbering exercises
importance of warm- Presas Remy A., MODERN ARNIS,
2. Muscle- strengthening
up exercise. Modern Arnis Publishing Co.
Revision 00-08132021 7|Page
Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

520 Quezon Boulevard,


Perform properly the Manila, 1974
different flexibility
exercise.
Presas Remy A., THE PRACTICAL
ART OF ESKRIMA, Modern Arnis
Appreciate the Publishing Co. 520
contribution of Quezon Boulevard Manila, 1980
different exercise in
preventing muscle
https://www.youtube.com/
injury while Exercise
channel/
performing arnis.
UCaimyyl8ttsaKTBmaB13hxQ?
app=desktop

https://www.youtube.com/
results?
app=desktop&sp=mAEA&search
_query=matti+san+juan

4,6 TLO 4 Basic skills in arnis Week 2 hours Lecture Quiz Physical Education 3(individual
1. stances 4 Discussion and dual sports)
Identify the different 2. posture demonstra
basic skills in arnis. tion PNU Licensure Examination for
Teachers Handout
Demonstrate the
proper way of Presas Remy A., MODERN ARNIS,
executing the Modern Arnis Publishing Co.
different arnis skills. 520 Quezon Boulevard,
Appreciate the Manila, 1974
benefits derived from
using the appropriate Presas Remy A., THE PRACTICAL
skills in arnis. ART OF ESKRIMA, Modern Arnis
Publishing Co. 520
Revision 00-08132021 8|Page
Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

Quezon Boulevard Manila, 1980

Identify the different https://www.youtube.com/


traditional striking channel/
techniques. UCaimyyl8ttsaKTBmaB13hxQ?
app=desktop
Appreciate the Description of the
importance of the traditional striking https://www.youtube.com/
different traditional techniques. results?
striking techniques. app=desktop&sp=mAEA&search
_query=matti+san+juan

4,6 Physical Education 3 for College,


Antonio Calicdan

PNU Licensure Examination for


Teachers Handout

Presas Remy A., MODERN ARNIS,


Modern Arnis Publishing Co.
520 Quezon Boulevard,
TLO 5 Manila, 1974
Identify the six
striking techniques in Presas Remy A., THE PRACTICAL
Week 4 hours Lecture
arnis ART OF ESKRIMA, Modern Arnis
5-6 Discussion performance Publishing Co. 520
Demonstrate the demonstra Quezon Boulevard Manila, 1980
proper way of tion
executing the striking https://www.youtube.com/
techniques. channel/
The six basics striking
UCaimyyl8ttsaKTBmaB13hxQ?
techniques
Appreciate the app=desktop
importance of each
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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

https://www.youtube.com/
results?
striking techniques. app=desktop&sp=mAEA&search
_query=matti+san+juan

Physical Education 3 for College,


Antonio Calicdan

PNU Licensure Examination for


Teachers Handout

TLO 6 Presas Remy A., MODERN ARNIS,


Identify the different Modern Arnis Publishing Co.
Blocking Techniques
blocking techniques in 520 Quezon Boulevard,
arnis. 1. right sideward upward
block Manila, 1974

Demonstrate the 2. left sideward upward


Lecture Presas Remy A., THE PRACTICAL
proper way of block
Discussion ART OF ESKRIMA, Modern Arnis
executing the 3. right sideward Week Performance
4,6 4 hours Demonstra Publishing Co. 520
blocking techniques in downward block 7-8
te Quezon Boulevard Manila, 1980
arnis. 4. left sideward downward
block
https://www.youtube.com/
Appreciate the 5. vertical block channel/
benefits derived from 6. rising block UCaimyyl8ttsaKTBmaB13hxQ?
using the appropriate app=desktop
blocking techniques in
arnis
https://www.youtube.com/
results?
app=desktop&sp=mAEA&search
_query=matti+san+juan

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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

Physical Education 3 for College,


Antonio Calicdan
PNU Licensure Examination for
Teachers Handout

Presas Remy A., MODERN ARNIS,


Modern Arnis Publishing Co.
520 Quezon Boulevard,
TLO 7 Manila, 1974
Demonstrate the
proper way of Presas Remy A., THE PRACTICAL
SINAWALI Lecture
executing the single ART OF ESKRIMA, Modern Arnis
Discussion Publishing Co. 520
and double sinawali. Week
4,6 4 hours demonstra performance Quezon Boulevard Manila, 1980
Final performance 9-10
tion
Appreciate the
importance of singe https://www.youtube.com/
and double sinawali in channel/
arnis. UCaimyyl8ttsaKTBmaB13hxQ?
app=desktop

https://www.youtube.com/
results?
app=desktop&sp=mAEA&search
_query=matti+san+juan

Week 2 hours Written Exam


MIDTERM EXAMINATION
11 Performance/Final Performance)
1 TLO 8 General Information Week 2 hours  Lecture  Quiz https://
Trace the history of 12  Discussion phlconnect.ched.gov.ph/home
badminton. 1.Historical Overview
2. Nature and https://www.youtube.com/
Discuss the nature of Development of Badminton results?
the game. app=desktop&sp=mAEA&search
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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
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Analyze the
development of the
game badminton. _query=badminton+family

Appreciate the Physical Education 3 for College,


contribution of Antonio Calicdan
different countries to
the development of
the game

TLO 9
Illustrate/ draw the
correct dimension of
the badminton court.
Physical Education 3 for College,
Antonio Calicdan
Identify the facilities
Lecture
and equipment Quiz
needed in playing
Facilities and Equipment Week Discussion https://www.youtube.com/
2,3 2 hours performance
badminton. 13 demonstra results?
tion app=desktop&sp=mAEA&search
_query=badminton+family
Familiarize the
specifications of the
different equipment in
playing badminton.

4 TLO 10 Preparing your Body for Week 2 hours Lecture Quiz Physical Education 3(individual
Explain the Badminton Activity 14 Discussion performance and dual sports)
importance of warm- 1. Warm-up Activities demonstra
up exercise https://www.youtube.com/
tion
. results?
Demonstrate the app=desktop&sp=mAEA&search
proper procedure for _query=badminton+family
flexibility exercise

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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

Determine the
benefits of flexibility
exercises.

Appreciate the
contribution of warm-
up exercise in
preventing muscle
injury while playing
badminton.

TLO 11

Demonstrate the
proper way of
executing the Physical Education 3(individual
badminton skills. and dual sports)
Basic skills in badminton
Lecture
Appreciate the Week Quiz https://www.youtube.com/
4 2 hours Discussion
benefits derived from 1. skill activities 15 results?
using the appropriate app=desktop&sp=mAEA&search
skills in badminton _query=badminton+family
game
Identify the different
basic skills in
badminton.

5 TLO 12 Rules and Regulations of Week 2 hours Lecture Quiz Physical Education 3(individual
Familiarize oneself the game 16 Discussion and dual sports)
with the basic rules
and regulations in https://www.youtube.com/
playing badminton. results?
app=desktop&sp=mAEA&search

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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

Apply the basic rules


in different game _query=badminton+family
situations.

TLO 13
Perform properly the
different badminton
drills.

Develop appropriate
level of muscular
strength and Physical Education 3(individual
endurance needed in and dual sports)
Lecture
playing badminton
Discussion  Quiz
through drills and Week https://www.youtube.com/
6 exercise 2 hours demonstra  performa
17 results?
tion nce app=desktop&sp=mAEA&search
Badminton Drills and
demonstrate the Terminologies _query=badminton+family
different badminton
drills

Appreciate the
importance derived
from badminton drills.

WEEK
18 Written Exam
FINAL EXAMINATION 2 HOURS
Performance/Lab. Exam (if Applicable)

V. GRADING SYSTEM

Assessment Task Midterm Period Final Period Targets and Standards

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Republic of the Philippines
President Ramon Magsaysay State University
Zambales
Telefax : 047-8111683/email address: prmsu.edu.ph

Class Standing
(10%)- Attendance/
Recitation/Participation
50% 50%
(10%)-Assignment/Quizzes/
Exercises
(30%)- Performance
Major Exams (Major Exam – 90% and above of the class obtaining at
Written or Performance/Lab. Exam, least passing rate of 75% and above
Project) 50% 50% (college based judgement)
Note : Flexi percentage: college-based
decision
Total 100% 100%
SEMESTRAL GRADE = 50% MIDTERM GRADE + 50% FINAL GRADE

VI. COURSE-LEVEL CURRICULUM MAP

Legend: I – Introductory; E – PROGRAM EDUCATIONAL


PROGRAM INTENDED LEARNING OUTCOMES (PILOs)
Enabling; D – Demonstrative OBJECTIVES (PEO)

COURSE INTENDED
PILO PILO PILO PILO PILO PILO PILO PILO PILO PILO PILO PILO PEO PEO PEO PEO
LEARNING OUTCOMES
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4
(CILOs)

CILO 1

CILO 2

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CILO 3

CILO 4

VII. ADDITIONAL/SUGGESTED READINGS

Physical Education 3(individual and dual sports)

VIII. CLASS POLICIES

A student is considered officially dropped only upon submission of the


instructor’s copy of the duly accomplished dropping slip before the scheduled
DROPPING deadline for dropping. A student who has dropped the course but fails to
submit the instructor’s copy at least two (2) weeks before the last day of
classes will be given a grade of 5.0. (refer to student handbook)

MISSED MAJOR EXAMINATIONS Any late submission of/missed quizzes, homework and activities will have a
MISSED ACTIVITIES grade of zero. Unexcused exam absence will automatically merit the student a
grade of zero. For an excused exam absence, the student will be given a grade
of INC and a chance to take the equivalent examination, i.e. similar topics, in a
future Specs 500 class. A valid excuse is qualified as either death of family
members up to the second degree of consanguinity, confinement due to a
serious medical condition (certified by a doctor who is not related to the
student), or representing the college/ university in competitions. It is the
student’s duty to establish the veracity of the excuse. This should be
coordinated with the instructor as soon as possible/in the meeting following
the exam. Only one examination may be excused in this manner.

Special Exam/Missed Major Exam


If you have missed faculty-conducted exam due to illness or misadventure,

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you may apply for an alternative exam. (refer to student handbook)

Special Circumstances/Special Needs


Students with disability or ongoing illness can make arrangements with the
professor/instructor regarding the different assessment tasks (e.g. projects,
exam, quiz) to minimize or eliminate the impact of his/her disability. However,
meeting the learning objectives of the subject must be observable. The
arrangements will involve modifications of the assessment tasks (e.g.
performance task) but maintain academic standards. (refer to RA 7227)

Special Consideration/Missed Activities


Special consideration consists of the exercise of academic discretion to provide
equitable treatment to students whose performance in an assessment item is
affected by illness, accident or work-related circumstances and for single
parent (as per RA 8972/Solo Parent Act).
You should only apply for special consideration when your performance in an
assessment item, including examinations, has been affected by extenuating or
special circumstances beyond your control. Special consideration is not
automatically guaranteed and may not result in a mark adjustment. (faculty
discretion)
For students involved in religious, sports and cultural activities (athletes,
performing artist) will also be given considerations, only if they present the
program of activity and excuse letter from their respective pastor or coaches.
(refer to student manual/memo from OUP)

ACADEMIC INTEGRITY It is expected that the student follows the highest principles of academic
honesty. Any form of work that will be submitted should be their own or
should have the work of others clearly documented and acknowledged. All
students must be committed to the principles of intellectual honesty and
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integrity. Once found responsible of an academic dishonesty violation


(cheating, fabrication, plagiarism, sabotage, participation in academically
dishonest activities, facilitating academic dishonesty, etc), a student will be
subjected to the University's rules and regulations which may result to a failing
mark and expulsion from the university.
Cheating in quizzes, homework, and exams, as well as academic dishonesty in
general, will not and never be tolerated. Any attempt at cheating in any
requirement will entail the student an automatic grade of 5.00, and the case
will be forwarded to the Student Disciplinary Council (SDC). Course
withdrawals to avoid getting a grade of 5.0 in these cases will not be
permitted. (refer to Student Handbook)

Due to this pandemic face to face consultation is not encouraged. To ensure


the instructor’s availability, schedule an appointment with the instructor.
Consultation via e-mail is encouraged as well. Please state your question as
CONSULTATION completely as possible. Consultation through phone will only be entertained if
the student introduces himself/herself and follows courteous language. (refer
to faculty manual/individual faculty teaching load)

SPECIAL SERVICES If you are a student with special needs and require accommodations, you must
be registered with the University’s Guidance and Counseling Office (GCO).
Students must provide current documentation to GCO which identifies their
special needs and need for accommodation(s). Students must meet instructors
with appropriate notification from GCO of the approved accommodation as
early in the semester as possible. You may learn more about the services of
the GCO by visiting its office.

Note: For other academic and student policy, please refer to the student

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handbook/manual.

Prepared by: Reviewed: Endorsed for Utilization:

Instructor I Program Chair, Bachelor Secondary Education Dean, College of Teacher Education

Date : Date : Date :

Note: Accomplish Annex A

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Annex A
AGREEMENT BETWEEN FACULTY AND STUDENT
(Source/s : CMO’s)

I, __________________________________________________________ with Home Address ______________________________________________________


officially enrolled student this ___________ A.Y. ________________ at President Ramon Magsaysay State University, agreed and sworn to adhere the academic
policies stipulated in the course syllabus and diligently comply with all the requirements of this course.

_______________________________________
(Student Signature over Printed Name/Date)

Witness:

______________________________________________________
(Parent’s/Guardian Signature Over Printed Name)

______________________________________________________
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(Faculty Signature over Printed Name/Date)

Note : Please return this accomplished form to the concerned faculty.

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