Republic of the Philippines

NUEVA VIZCAYA STATE UNIVERSITY

COLLEGE OF ARTS AND SCIENCES
Bambang, Nueva Vizcaya

STUDENT INTERNSHIP PROGRAM APPLICATION FORM

PART I. TO BE FILLED BY THE STUDENT TRAINEE (Write Legibly)

Family Name Gender

First Name Civil Status
Middle Name Contact Number
Course & Year
Home Address
Boarding
Address
Time Day
SIP/OJT
Schedule
I hereby promise to abide with the policies, rules, and guidelines of the Student Internship Program (SIP) of the Nueva
Vizcaya State University.

____________________________________
Name and Signature of Student Trainee

Recommended by:

______________________________
OJT Coordinator/Adviser/ Program Chair, BSPA

APPROVED:

GERARDO S. IBASCO JR. PhD

Dean

=========================================================================
OJT REQUIREMENTS CHECKLIST
No. Items/Documents Remarks
1 Evaluation of Grades
2 SIP Application Form
3 Student Consent Form
4 Parental /Guardian Consent Form and Liability Waiver
(In-Campus)(Off-campus)
5 Student Trainee Form
6 Certificate of Good Moral Character
7 Photocopy of Birth Certificate (PSA)
8 Community Tax Certificate (Cedula)
9 Barangay Clearance
Police Clearance
MTC Clearance
NBI Clearance
10 Medical Certificate
Antigen Test
Chest X-ray Film
Pregnancy Test
Fully Vaccinated with Booster (Yes/No), Specify:
11 Affidavit of Consent and Waiver (Off-Campus)
Remarks: C-Complied NC-Not Complied W-Waived NA- Not Applicable

2 nd Semester S.Y. 2022-2023 Bachelor of Science in Public Administration

 Republic of the Philippines
NUEVA VIZCAYA STATE UNIVERSITY
COLLEGE OF ARTS AND SCIENCES
Bambang, Nueva Vizcaya

STUDENT TRAINEE FORM

A. PERSONAL DATA

1. Name __________________________
2. Permanent Address __________________________
3. Residence Address __________________________
4. Age __________________________
5. Date of Birth __________________________
6. Place of Birth __________________________
7. Civil Status __________________________
8. Height __________________________
9. Weight __________________________
10. Contact Number __________________________
11. E-mail Address __________________________

12. Father’s Name __________________________

13. Occupation __________________________
14. Address __________________________
15. Mother’s Name __________________________
16. Occupation __________________________
17. Address __________________________
18. Brother’s Name __________________________
19. Sister’s Name __________________________
20. Language or Dialect Spoken __________________________
21. Person to Contact in Case of Emergency __________________________
22. Address __________________________

B. EDUCATIONAL BACKGROUND

Elementary School __________________________________________

School Address __________________________________________
Date Graduated __________________________________________

High School __________________________________________

School Address __________________________________________
Date Graduated __________________________________________

College __________________________________________
School Address __________________________________________
Date Graduated __________________________________________
Course __________________________________________
2 nd Semester S.Y. 2022-2023 Bachelor of Science in Public Administration
 Republic of the Philippines
NUEVA VIZCAYA STATE UNIVERSITY
COLLEGE OF ARTS AND SCIENCES
Bambang, Nueva Vizcaya

Special Skills __________________________________________

Others __________________________________________

C. SEMINARS ATTENDED

D. ON THE JOB TRAINING (Check/Fill up Appropriate Box)

[ ] National Government Agency/State Universities and Colleges
[ ] Local Government Unit
[ ] Government-Owned and Controlled Corporation
[ ] Non- Government Organizations
[ ] Private Agencies

E. SKILLS
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________

D.CHARACTER REFERENCES (not related to you)

Name Occupation Address

_________________ ___________________ _________________________

_________________ ___________________ _________________________
_________________ ___________________ _________________________

Comm. Cert. No.__________ Date Issued____________ Issued at_______________

__________________________________
Name and Signature

2 nd Semester S.Y. 2022-2023 Bachelor of Science in Public Administration

 Republic of the Philippines
NUEVA VIZCAYA STATE UNIVERSITY
COLLEGE OF ARTS AND SCIENCES
Bambang, Nueva Vizcaya

2 nd Semester S.Y. 2022-2023 Bachelor of Science in Public Administration