BPSU-ASF-011(Revision 0; March,2018)

BATAAN PENINSULA STATE UNIVERSITY

City of Balanga 2100 Bataan
PHILIPPINES

APPLICATION FOR PERMISSION TO TEACH

Instruction: (1) Accomplish this form in quadruplicate.
(2) Application must be made one week before the first day of classes.

PERSONAL INFORMATION
Name
(Last Name) (Given Name) (Middle Name)
 Single
 Married 11/04/1987  Male
Civil Status Date of Birth Sex
 Separated  Female
 Widow/er (ddmmyyyy)
 Main
 Orani
INSTRUCTOR I Salary 12
Campus  Balanga Position
Grade
 Abucay
 Dinalupihan
 Casual
 Teaching  Full-Time
Classification Nature Tenure  Contractual
 Non-Teaching  Part-Time
 Permanent
Office / Performance  Outstanding  Fair
Institute / Rating for the Last  Very Satisfactory  Poor
College Rating Period  Satisfactory
EDUCATIONAL QUALIFICATIONS
College / University Degree Pursued/Finished and Year Completed

ACTUAL OFFICE / TEACHING HOURS (BPSU)

Subject Units Hours
Day(s) Time Room Subject Title Section
Code Lec Lab Lec Lab
Tuesday
Wednesday

Thursday

Friday

Total
Academic Year Attested by: Confirmed by:

_______ __
Semester  1st  2nd  3rd
Dean / Department Head Vice President, Academic Affairs

NATURE OF TEACHING JOB / SCHEDULE

Name of College/University Mary the Queen College (Pamp.), Inc.
Department/Institute/College Senior High School
Subject Units Hours
Day(s) Time Room Subject Title Section
Code Lec Lab Lec Lab

Academic Year 2022 - 2023 Attested by: Confirmed by:

_.__ ___
Semester  1st  2nd  3rd
Dean / Department Head Vice President, Academic Affairs

I hereby pledge that my intention to DO NOT FILL OUT THIS PORTION

teach will not affect nor compromise my
actual and official duties and functions ACTION TAKEN
Recommending Approval:
as well as the thrusts of the University.
APPROVED DISAPPROVED
__________________________
Signature of Applicant
_._
_________ Vice President, Academic Affairs
Date University President
THIS PERMIT IS VALID ONLY FOR THE ABOVE-CITED ACADEMIC YEAR AND SEMESTER.