FM-AA-INT-01

Rev. 0
01-Feb-2017

APPLICATION FOR INTERNSHIP

PANGASINAN STATE UNIVERSITY

A. PERSONAL PROFILE
NAME Reyes Blessie Joy Fernandez

AGE 21 CIVIL STATUS Single

SEX Female CONTACT NUMBER 09773772878
COURSE Bachelor of Public Administration YEAR & SECTION IV-B
MAJOR PARENT/GUARDIAN Florence D. Reyes/Malgie F. Reyes
CURRENT ADDRESS Bugallon Pangasinan
HOME ADDRESS #1534 Sitio Salincaoet Poblacion Bugallon Pangasinan
B. ACADEMIC CREDENTIALS/QUALIFICATIONS

This is to certify that as per records kept in this office, the above name had already taken and pass ______ units except the following subject/s to wit:

SEM SY SUBJECT PASSING FAILING GRADE SIGNATURE DATE

2021- Ethics and Accountability in
1st
2022 Phblic Service
2021-
1st Special Topics in P.A
2022
2021-
1st Voluntary Sector Management
2022
2021- Research in Public
1st
2022 Administration II
2021- Office and System
1st
2022 Management

This is to certify that he/she is ________________ to undergo internship.

Certified and verified true and correct:

HELEN BRAGA-MABANTA
Registrar III

C. FIRM/AGENCY/COMPANY FOR INTERNSHIP

NAME OF THE
FIRM/AGENCY/COMPANY
ADDRESS
HEAD
CONTACT NUMBER
NUMBER OF HOURS

Note: Please attach Medical Certificate and Psychological Test from any government physician, certifying that the student applicant is physically,
emotionally, and mentally fit for the internship training activity.

RECOMMENDING APPROVAL

. MR. MENARD P. NAVA DR. ABELARDO S. ABALOS, JR.

Internship/Practicum Subject Instructor Campus Internship Coordinator

MR. JANDY Z. CACAPIT DR. NOVA E. ARQUILLANO

Department Chair College Dean, CBPA

DR. RANDY JOY M. VENTAYEN

Campus Executive Director