FM-AA-INT-03

Rev. 0
03-Oct-2017

CONSENT AND WAIVER

PANGASINAN STATE UNIVERSITY

I, __________________________, Filipino of legal age, and residing at _________________________ after

being duly sworn by law, do hereby depose and say that:

1. I am a student of Pangasinan State University, Urdaneta Campus and that as a course requirement for
_______________________________________, I am required to undergo Internship / Practicum in any
company in line with my major field of specialization for 486 hours;

2. That the Pangasinan State University, Urdaneta Campus, thru the Campus Internship Coordinator and the
Internship /Practicum Subject Instructor has requested to allow me to undergo thereat
Company
and said company had accepted said request;

3. I promise to render the necessary work to the best of my ability in order that my practicum shall be brought to
a successful conclusion and that _____________________ and the Pangasinan State University, Urdaneta
Company
Campus shall not adversely affect;

4. That while performing the internship and the duration thereof, I shall abide by the rules and policies of said
Company and Pangasinan State University, Urdaneta Campus relative to the work covered by said internship
and such order and instruction issued or to be issued thereby;

5. I shall be punctual in my attendance and shall abide by the evaluation given me by said company based on
such internship;

6. I declare unconditional that there exists no employer-employee relationship between

Company
and me, and hereby hold its officers, directors and personnel free and harmless from any case or causes of
action, claims or otherwise arising from or about my internship which I have, including money claims, it
understood that the internship is just a part of the academic preparation and thus non-compensable;

7. I further hold Pangasinan State University, Urdaneta Campus, its officers, coordinator and personnel and
______________________ free and harmless from any liability whatsoever during the period of my internship
Company
immediately thereafter while on my way to and/or the office of the ______________________ to perform my
Company
internship while performing the same while in the premises thereof.

Signed at Urdaneta, Pangasinan. This ___ day of ________, 2018.

WITNESSES: CONFORME:

__ _KRISTEN BHING V. SALVIO_____ ___________________________________

Campus Internship and Placement Coordinator Signature over Printed Name of Student

Residence Cert. No.: ____________

NOTED: Issued at: _____________________
Issued on: _____________________

_ _DR. GEMMA M. DE VERA_____

Campus Executive Director
________ _________________________
Signature over Printed Name of Parent/Guardian