Republic of the Philippines

BULACAN STATE UNIVERSITY

SAS STUDENT WELFARE AND DEVELOPMENT
CAREER DEVELOPMENT AND STUDENT INTERNSHIP SERVICES

CHECKLIST OF DOCUMENTARY REQUIREMENTS

Name of Intern: Jem Edison L. Ucol Course/Yr &Section: BSIT 4C

Age: 21 Gender: Male
Contact #: 09059746785 Email add: jemedison022301@gmail.com
Type of Internship Program:*
☐On-Campus Internship
☐Face to face Internship
☐e-HTE with 1 day reporting on-site

Full Address of HTE:______________________________________________________

Directions: Kindly tick the box that has fully accomplished.

(Please note that non-compliance to any of the requirements will deter your deployment).

☐ Request letter for the conduct of F2F Internship. The request letter must be
accompanied with the following attachments saved in pdf file:
☐Approved work plan/training program
☐Copy of vaccination certificate. (Only fully vaccinated students will be allowed for the
F2F internship.)
☐Client Disclosure Form (Form A) and BulSU Medical Pre Internship Interview (to be
coordinated with the University Infirmary)
☐BulSU Psychoemotional Health Questionnaire Form (Form C) (to be coordinated with
the University Guidance Counseling Services Center)
☐Notarized Consent of Parent/Guardian

I certify that the above documents are correct and accomplished as part of the
documentary requirements needed for the
(* type of internship Program)

SIGNATURE OVER PRINTED NAME OF INTERN

SIGNATURE OVER PRINTED NAME OF PARENT

Certified true by:

SIGNATURE OVER PRINTED NAME OF SIP COOR

Career Development & Student Internship Services- Ground Floor, Roxas Hall, Bulacan State University
Tel No. (044) 919-7800 loc. 1077 Email; cardsis@bulsu.edu.ph