Republic of the Philippines

Department of Education
REGION I
SCHOOLS DIVISION OFFICE I PANGASINAN
AGNO NATIONAL HIGH SCHOOL
Poblacion West, Agno, Pangasinan

SENIOR HIGH SCHOOL DEPARTMENT

APPLICATION FORM FOR WORK IMMERSION
2nd Semester, S.Y. 2023-2024

A. PERSONAL PROFILE
NAME: _______________________________________________________________________________________
Surname Given Name M.I.
GRADE & SECTION: _________________________________________
TRACK: _________________________________________ Strand: _____________________
COMPLETE HOME ADDRESS: ___________________________________________________________________
___________________________________________________________________
LOCAL ADDRESS (if boarding): ___________________________________________________________________
___________________________________________________________________
CONTACT NUMBER: _________________________________________

B. ACADEMIC PROFILE
I. Core Subjects

SUBJECT TITLE RATING TEACHER

II. Applied Subjects

SUBJECT TITLE RATING TEACHER

Address: Poblacion West, Agno, Pangasinan
Contact No.: 0998-535-3062
Email: 300154@deped.gov.ph
 Republic of the Philippines
Department of Education
REGION I
SCHOOLS DIVISION OFFICE I PANGASINAN
AGNO NATIONAL HIGH SCHOOL
Poblacion West, Agno, Pangasinan

III. Specialized Subjects

SUBJECT TITLE RATING TEACHER

C. What aspects of work immersion do you expect to encounter difficulties? List at

least 5.
1. _________________________________________________________________________________
2. _________________________________________________________________________________
3. _________________________________________________________________________________
4. _________________________________________________________________________________
5. _________________________________________________________________________________

D. What tasks/activities relevant to your track & strand can you do with high level of
proficiency? List at least 5.
1. _________________________________________________________________________________
2. _________________________________________________________________________________
3. _________________________________________________________________________________
4. _________________________________________________________________________________
5. _________________________________________________________________________________

Address: Poblacion West, Agno, Pangasinan

Contact No.: 0998-535-3062
Email: 300154@deped.gov.ph
 Republic of the Philippines
Department of Education
REGION I
SCHOOLS DIVISION OFFICE I PANGASINAN
AGNO NATIONAL HIGH SCHOOL
Poblacion West, Agno, Pangasinan

E. What skills/competencies relevant to your track & strand have your mastered? List
at least 5.
1. ____________________________________________________________
2. ____________________________________________________________
3. ____________________________________________________________
4. ____________________________________________________________
5. ____________________________________________________________

Attachment:
 Medical Certificate
 Certificate of Good Moral Character

____________________________________
Signature Over Printed Name

Certified True and Correct:

ELSIE ORCAJO
School Registrar

APPROVED:

FRANKLIN V. FERNANDEZ EdD

Head Teacher III
Work Immersion Teacher

Address: Poblacion West, Agno, Pangasinan

Contact No.: 0998-535-3062
Email: 300154@deped.gov.ph