Republic of the Philippines

POLYTECHNIC UNIVERSITY OF THE PHILIPPINES

Office of the Vice President for Academic Affairs
MECHANICAL ENGINEERING DEPARTMENT
OFFICE OF THE CHAIRPERSON

WAIVER
I, John Alnie P. Caro, an incoming 3 rd Year Mechanical Engineering student of age 20 and
residing at Newtown 1, Minuyan Proper, San Jose del Monte, Bulacan and an applicant for
the On-the-Job Training with a cooperating company, Republic Cement & Building
Materials Norzagaray Plant, Inc, through the request of the Polytechnic University of the
Philippines, and in consideration thereof, do hereby freely and accept the following duties:

1. That I recognize the authority of my cooperating company, Republic Cement &

Building Materials Norzagaray Plant, Inc, where I will be placed and submit myself to
all the reasonable rules and regulations that are imposed upon me in connection
with my training. And;

2. That I renounced and waive any claim against the cooperating company, Republic
Cement & Building Materials Norzagaray Plant, Inc and the Polytechnic University of
the Philippines for any injury that I may sustain, or loos that I may suffer, personal and
pecuniary, in the performance of my duties or function while under training.

Signed in the City of _______________, Philippines, this __ day of August 2023.

John Alnie P. Caro

Student No. 2021-04843-MN-0

WITNESS:

With the consent and approval of Parent/Guardian:

_____________________________ Date: ________________ ID No. ________________

Signature Over Printed Name

Address: ___________________________________________________________________________

SUBSCRIBED AND SWORN to before me this ___ day of August 2023 at _______, Philippines.
Affiant having exhibited to me his Student ID with student number 2021-04843-MN-0.

Doc. No.________
Page No.________
Book No.________
Second Floor, College of Engineering and Architecture Building,
PUP A. Mabini Campus, Anonas Street, Sta. Mesa, Manila 1016
Direct Line: 335-1752 | Trunk Line: 335-1787 or 335-1777 local 236 or 302
Website: www.pup.edu.ph | Email: ce@pup.edu.ph Tel no: 716-6273

THE COUNTRY’S 1 POLYTECHNICUst

Series of 2023

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