FM-AA-PPT-02

Rev. 03
06-Feb-2023

APPLICATION FOR PRACTICE TEACHING

PANGASINAN STATE UNIVERSITY
Lingayen Campus

ADDRESS CONTACT NUMBER

PRACTICE TEACHING COORDINATOR
ACADEMIC YEAR PERIOD OF PRACTICE TEACHING Semester :

A. PERSONAL PROFILE

NAME
Last Name First Name M. I.
PROGRAM AND
SPECIALIZATION
STUDENT NUMBER
PRESENT ADDRESS
(Attach a recent 2x2 picture with
PERMANENT ADDRESS white background)
MOBILE NUMBER EMAIL ADDRESS
RECEIPT NO. (ST Fee)
TYPE OF COMMUNITY IN WHICH YOU HAVE LIVED THE MAJOR PART OF YOUR LIFE:
Barrio/Sitio Town/Poblacion City
BIRTHDAY CIVIL STATUS
HEIGHT (in cm) WEIGHT (in kg)
NAME OF FATHER OCCUPATION
HIGHEST EDUCATIONAL ATTAINMENT
Elementary High School College
NAME OF MOTHER OCCUPATION
HIGHEST EDUCATIONAL ATTAINMENT
Elementary High School College
ANNUAL FAMILY
INCOME ESTIMATED MONTHLY ALLOWANCE

NUMBER OF SIBLINGS POSITION IN THE FAMILY

NAME OF SPOUSE (if married)
B. INDICATE THE COOPERATING SCHOOL WHERE YOU PREFER TO BE ASSIGNED:
FIRST CHOICE
SECOND CHOICE
THIRD CHOICE

Practice Teacher’s Signature over Printed

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

Vaccination Card or Certificate Urinalysis Blood Pressure Personality Test

Medical Certificate CBC, Plt Chest X-ray

D. ACTION TAKEN
Qualified for practice teaching Not qualified for practice teaching reason/s for disapproval:
not physicaly fit
other reasons (pls specify):
EVALUATED BY: NOTED BY: APPROVED:

Coordinator, Practice Teaching College Dean, Teacher Education

Department Chairman, Professional Education

Date: Date: Date: