Reference No.: BatStateU-FO-OJT-02 Effectivity Date: January 3, 2017 Revision No.

: 00

STUDENT TRAINEE’S PERSONAL HISTORY STATEMENT “1X1”

PICTURE

Student Information
LAST NAME: Villanueva FIRST NAME: Dianne MIDDLE NAME: Maramot
AGE: 20 SEX MALE FEMALE
HEIGHT: 161 cm WEIGHT: 49 kgs COMPLEXION:
DISABILITY(IF ANY)

BIRTHDATE: 0 3 2 7 9 8 BIRTHPLACE: Batangas City

(mm dd yy)

CITIZENSHIP:Filipino CIVIL STATUS: Single

PRESENT ADDRESS: San Pedro, Bauan, Batangas TEL NO. 403-4791
PROVINCIAL ADDRESS San Pedro, Bauan, Batangas TEL NO. 403-4791

Family Background (if parents are deceased, give data for the nearest relative and indicate relationship to applicant)

FATHER’S NAME: Avelino C. Villanueva OCCUPATION: Electrician

MOTHER’S NAME: Rosario M. Villanueva OCCUPATION: None
ADDRESS OF PARENTS: San Pedro, Bauan, Batangas TEL. NO.: 403-4791
GUARDIAN’S NAME: Rosario M. Villanueva TEL. NO.: 403-4791
SCHOOL INFORMATION
PROGRAM: Engineering YEAR LEVEL: 5th year
MAJOR: Chemical LENGTH OF PROGRAM: 5 years
SCHOOL ADDRESS: GCH, Brgy. Alangilan,
DEPARTMENT: Chemical and Food
Batangas City, Batangas
OJT COORDINATOR: Rodolfo C. Sotto, Jr. TEL. NO.:
OJT ASST. DIRECTOR: Adrian Ferdinand M. Melo TEL. NO.:
DEAN: Elisa D. Gutierrez TEL. NO.:
In case of emergency, notify
NAME: Rosario M. Villanueva RELATIONSHIP: Mother
ADDRESS: San Pedro, Bauan, Batangas TEL. NO.: 09667524821

I hereby certify that the foregoing answers are true and correct to the best to my knowledge, belief and ability.

Signed at: Batangas State University-Main Campus II Date: August 24, 2018

Dianne M. Villanueva
Applicant’s Signature over Printed Name