APPLICATION FOR PRACTICE TEACHING

PANGASINAN STATE UNIVERSITY

San Carlos City Campus

CAMPUS SAN CARLOS CITY CAMPUS ADDRESS ROXAS BOLUEVARD SAN CARLOS CITY, PANGASINAN
PRACTICE TEACHING COORDINATOR CRELEAH R. MENOR,MAEd CONTACT NUMBER O9496057481
ACADEMIC YEAR 2021-2022 PERIOD OF PRACTICE TEACHING School Year 2021-2022
A. PERSONAL PROFILE

NAME ACOSTA DANICA R.

Last Name First Name M. I.

COURSE AND SPECIALIZATION BACHELOR OF SECONDARY EDUCATION MAJOR IN SOCIAL

STUDIES
STUDENT NUMBER 19-SC-0363

HOME ADDRESS #77 Roxas Boulevard, San Carlos City, Pangasinan

LOCAL ADDRESS #77 Roxas Boulevard, San Carlos City, Pangasinan

MOBILE NUMBER 09451886285 EMAIL ADDRESS acostadanicayshen@gmail.com

RECEIPT NO. (ST Fee)

TYPE OF COMMUNITY IN WHICH YOU HAVE LIVED THE MAJOR PART OF YOUR LIFE:

Barrio/ Sitio Town/ Poblacion City

BIRTHDAY December 11, 1999 CIVIL STATUS SINGLE

HEIGHT 5’5 WEIGHT 56kg.
NAME OF FATHER Orlando G. Acosta OCCUPATION US Navy Retiree
HIGHEST EDUCATIONAL ATTAINMENT
Elementary High school College

NAME OF MOTHER Judith R. Acosta OCCUPATION House Wife

HIGHEST EDUCATIONAL ATTAINMENT
Elementary High school College

ANNUAL INCOME OF PARENTS N/A ESTIMATED MONTHLY ALLOWANCE N/A

NUMBER OF SIBLINGS 3 POSITION IN THE FAMILY Youngest
NAME OF SPOUSE

ACOSTA, DANICA R.
Practice Teacher’s Signature over Printed Name
Date: February 18, 2022

C. MEDICAL AND PSYCHOLOGICAL RESULTS (Please submit or attach a copy of the certification/results)

Medical Certificate Vaccination Card or Certificate

D. ACTION TAKEN

Qualified for Practice Teaching Not qualified for Practice Teaching

Reason/s for disapproval:
not physically fit
other reasons (pls. specify):

EVALUATED BY: NOTED BY: APPROVED:

Coordinator, Practice Teaching Chairman, Professional Education Department Dean, College of Teacher Education

Date: Date: Date: