Center of Development in Information Technology

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Don Mariano Marcos Memorial State University MID-LA UNION CAMPUS

College Of Information Technology Center of Development in Information Technology


City of San Fernando, La Union Website: http://www.dmmmsu-mluc.edu.ph Telephone: (072) 242-4849

APPLICATION FOR COOPERATIVE INDUSTRIAL TRAINING PROGRAM


December 3, 2013 DR. EDUARDO C. CORPUZ Dean, CIT This Campus Sir: I have the honor to apply for admittance into the Cooperative Industrial Training Program this2nd Semester, School Year 2012-13. Name: CHAN KENDRIX __________RUPINTA (Surname) (Given name) (Middle Name) Date of Birth: MAY 18, 1989 Place of Birth: SEVILLA, CITY OF SAN FERNANDO, LA UNION Age: 24 Sex: MALE Height (cm): 160 Weight (Kg): 54 Residence Address:BRGY 4, CITY OF SAN FERNANDO, LA UNION _ Course: B.S. INFORMATION TECHNOLOGY Cel./Tel. No.: 0946-8321-291 Place of Training/Assignment:CITY HALL OF SAN FERNANDO CITY, LA UNION Field of Assignment:PERMIT AND LICENSES Period of Training: NOVEMBER 2013-MARCH 2014 Address of Establishment/Company:PERMIT AND LICENSES SECTION CITY OF SANFERNANDO LA UNION Manager/Authorized Representative:OFELIA V. MENDOZA Cel./Tel.No.:888-6901 to 05 In case of emergency, please notify, WISON E. CHAN Pindangan, City of San Fernando, La Union Contact No.:0948-310-0462

I hereby certify that the answers given above are true and correct to the best of my knowledge and belief. Very truly yours,

KENDRIX R. CHAN Signature over Printed Name

Your Right Thumb Mark

WISON E. CHAN Signature of Parent/Guardian over Printed

Noted:

Recommending Approval:

Approved:

BERNARDO D. LAMADRID, MIT OJT Coordinator


prepare dby bdlama drid2 012

ZHELLA ANNE V. NISPEROS, MIT Chairperson, BS Info. Tech.

EDUARDO C. CORPUZ, Ph.D. Dean

PROGRAMS: Bachelor of Science in Information Technology Master in Information Technology

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