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PT Form 2 Application For Practice Teaching

This document is an application for practice teaching at Pangasinan State University. It requests personal information from the applicant such as name, program of study, medical results, and preferred schools for assignment. If qualified, the coordinator, department chair, and dean must approve the applicant for practice teaching. If not qualified, reasons must be provided such as physical fitness or other issues. Final approval is determined by the dean of the College of Teacher Education.

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Elijah Marie Lindain Erfe
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79 views9 pages

PT Form 2 Application For Practice Teaching

This document is an application for practice teaching at Pangasinan State University. It requests personal information from the applicant such as name, program of study, medical results, and preferred schools for assignment. If qualified, the coordinator, department chair, and dean must approve the applicant for practice teaching. If not qualified, reasons must be provided such as physical fitness or other issues. Final approval is determined by the dean of the College of Teacher Education.

Uploaded by

Elijah Marie Lindain Erfe
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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FM-AA-PPT-02

Rev. 03
31-Jan-2023

APPLICATION FOR PRACTICE TEACHING


PANGASINAN STATE UNIVERSITY
Asingan Campus

CAMPUS ADDRESS
PRACTICE TEACHING COORDINATOR CONTACT NUMBER
ACADEMIC YEAR PERIOD OF PRACTICE TEACHING Semester
A. PERSONAL PROFILE

NAME
Last Name First Name M. I.
PROGRAM AND SPECIALIZATIO
STUDENT NUMBER
PRESENT ADDRESS
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 INCOME OF PARENTS ESTIMATED MONTHLY ALLOWANCE
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 CBC, Plt Blood Pressure Personality Test
Medical Certificate Urinalysis X-ray
D. ACTION TAKEN

Reason/s for disapproval:


Qualified for Practice Teaching Not qualified for Practice Teaching
not physically fit
other reasons (pls. specify):_____________________

EVALUATED BY: NOTED: APPROVED:

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

PRACTICE TEACHING COORDINATOR

ACADEMIC YEAR

NAME

Last Name

COURSE AND SPECIALIZATION


STUDENT NUMBER
HOME ADDRESS
LOCAL ADDRESS
MOBILE NUMBER
RECEIPT NO. (ST Fee)
TYPE OF COMMUNITY IN WHICH YOU HAVE LIVED THE MAJOR PART OF YOUR LIFE:
Barrio/Sitio Town/Poblacion City
BIRTHDAY
HEIGHT
NAME OF FATHER
HIGHEST EDUCATIONAL ATTAINMENT
Elementary High School College
NAME OF MOTHER
HIGHEST EDUCATIONAL ATTAINMENT
Elementary High School College
ANNUAL INCOME OF PARENTS
NUMBER OF SIBLINGS
NAME OF SPOUSE

FIRST CHOICE

SECOND CHOICE
THIRD CHOICE

BLOOD PRESSURE
URINALYSIS

CBC

Qualified for practice teaching

EVALUATED BY:

__________________________________
_
Coordinator, Practice Teaching
Date:
_______________________________
APPLICATION FOR PRACTIC
PANGASINAN STATE UNIVERSIT
Bayambang Campus

A. PERSONAL PROFILE

Last Name

EMAIL ADDRESS

B. INDICATE THE COOPERATING SCHOOL WHERE YOU PREFER TO BE ASSIGNED:

Practice Teacher’s Signature over Printed Name


Date:_____________________

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

SPUTUM
X-RAY

IQ TEST

D. ACTION TAKEN

practice teaching

NOTED BY:

___________________________________
Department Chairman, Professional Education
Date: _______________________________
ON FOR PRACTICE TEACHING
PANGASINAN STATE UNIVERSITY
Bayambang Campus

ADDRESS

CONTACT NUMBER

PERIOD OF PRACTICE TEACHING

First Name M. I.

EMAIL ADDRESS

CIVIL STATUS
WEIGHT
OCCUPATION

OCCUPATION

ESTIMATED MONTHLY ALLOWANCE


POSITION IN THE FAMILY

EFER TO BE ASSIGNED:

ame

h a copy of the certification/results)


Not qualified for practice teaching reason/s for disapproval:
____not physicaly fit
____other reasons (pls specify):_____________________

APPROVED:

_____________________________
_
College Dean, Teacher Education
Date:
_____________________________
School Year .
.

DRUG TEST
PERSONALITY TEST

APPROVED:

__________________________________
_
College Dean, Teacher Education
Date:
_______________________________

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