FM-AA-PPT-02

Rev. 03
06-Feb-2023

APPLICATION FOR PRACTICE TEACHING

___________________________________
___________________________________
___________________________________ PANGASINAN STATE UNIVERSITY
Lingayen Campus
College
Department Dean, Teacher
Coordinator,
Chairman,Practice Education
Teaching
Professional Education

ADDRESS
Date:
Date: _______________________________
Date:_______________________________
_______________________________ CONTACT NUMBER
PRACTICE TEACHING COORDINATOR
ACADEMIC YEAR PERIOD OF PRACTICE TEACHING Semester : . .

A. PERSONAL PROFILE

NAME
Last Name First Name M. I.

PROGRAM AND
SPECIALIZATION
STUDENT NUMBER
PRESENT ADDRESS (Attach a recent 2x2 picture with white
background)
PERMANENT ADDRESS
MOBILE NUMBER EMAIL ADDRESS
RECEIPT NO. (ST Fee)
TYPE OF COMMUNITY IN WHICH YOU HAVE LIVED THE MAJOR PART OF YOUR LIFE:
Barrio/Sitio Town/Poblacion City
BIRTHDAY CIVIL STATUS
HEIGHT (in cm) WEIGHT (in kg)
NAME OF FATHER OCCUPATION
HIGHEST EDUCATIONAL ATTAINMENT
Elementary High School College
NAME OF MOTHER OCCUPATION
HIGHEST EDUCATIONAL ATTAINMENT
Elementary High School College
ANNUAL FAMILY
ESTIMATED MONTHLY ALLOWANCE
INCOME
NUMBER OF SIBLINGS POSITION IN THE FAMILY
NAME OF SPOUSE (if married)
B. INDICATE THE COOPERATING SCHOOL WHERE YOU PREFER TO BE ASSIGNED:
FIRST CHOICE
SECOND CHOICE
THIRD CHOICE

Practice Teacher’s Signature over Printed Name

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

Vaccination Card or Certificate Urinalysis Blood Pressure Personality Test

Medical Certificate CBC, Plt Chest X-ray

D. ACTION TAKEN

Qualified for practice teaching Not qualified for practice teaching reason/s for disapproval:
not physicaly fit
other reasons (pls specify):
EVALUATED BY: NOTED BY: APPROVED: