Don Mariano Marcos Memorial State University

MID - LA UNION CAMPUS

College of Information Technology

Center of Development in Information Technology
City of San Fernando, La Union
Website: http://www.dmmmsu-mluc.edu.ph
Telephone: (072) 242-4849

COOPERATIVE INDUSTRIAL TRAINING PROGRAM

STUDENT INFORMATION SHEET
PERSONAL DATA
Name: ____________________________________________________
Status:
_____________
Course: ___________________________________________________
Contact #:
_________________
Address: ____________________________________ Place of Birth:
___________________________
Age: __________
Sex: ___________
Height: ____________
Weight:
____________
Physical disability if any:
_________________________________________________________________
FAMILY BACKGROUND
Fathers name: _________________________________
______________________
Mothers name: ________________________________
______________________
Parents Address: _____________________________________
_________________

Occupation:
Occupation:
Contact #:

SCHOOL DATA
Name of school:
_______________________________________________________________________
OJT Supervisor:
________________________________________________________________________
Dean:
________________________________________________________________________________
School Address:
________________________________________________________________________
IN CASE OF EMERGENCY PLEASE NOTIFY:
Name: ________________________________________
Contact #:
________________________
Address:
_____________________________________________________________________________
I HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE IS TRUE
AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

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1X1

Right
Thumb
mark

____________________________
Signature over printed name

(To be filled up by the student trainee)

PROGRAMS:

Bachelor of Science in Information Technology

Master in Information Technology

Don Mariano Marcos Memorial State University

MID - LA UNION CAMPUS

College of Information Technology

Center of Development in Information Technology
City of San Fernando, La Union
Website: http://www.dmmmsu-mluc.edu.ph
Telephone: (072) 242-4849

Expected Place of Training Station: ________________________________________________

Address: _____________________________________________________________________
Contact Person: _______________________________________________________________

PROGRAMS:

Bachelor of Science in Information Technology

Master in Information Technology