CENTRAL PHILIPPINES STATE UNIVERSITY

Kabankalan City, Negros Occidental

OJT/PRACTICUM/INTERNSHIP PROGRAM

STUDENT INFORMATION SHEET

ID No. Year and Program

Name Family Name First Name Middle Name

Sex Contact Age
No.
Mailing
Address

Place of Birth Date of Birth

Parent’s Information
Mother
Maiden Name First Name Middle Name
Father
Family Name First Name Middle Name
Home Address

Contact No.
Insurance Information
Company Policy Contract No.

Date of
Coverage
Host Training Establishment (HTE) Information
Name of
Agency
Address

Contact Person
Position
Contact No.

Student’s Signature

Date

Doc Control Code:CPSU-F-OJT-02 Effective Date:06/20/2019 Page No.:1 of 1