INDUSTRIAL IMMERSION

WORKBOOK 1
(Food Technology - 2)

A Comprehensive Self-Propelling Guide

_______________________________________
(Name of Trainee)

Raymund R. Baniaga
Judelyn R. Mandac
Jasper Kim M. Rabago
INDUSTRIAL IMMERSION
WORKBOOK 2
(Food Technology - 3)

A Comprehensive Self-Propelling Guide

_______________________________________
(Name of Trainee)

Raymund R. Baniaga
Ralp Kevin Barrolo
Jasper Kim M. Rabago
 APPROVAL SHEET

To Whom It May Concern:

This is to certify that all activities included in this On-the-Job

Training Workbook were actually undertaken by
__________________________________, an On-the-Job Trainee of Mariano
Marcos State University- College of Industrial Technology, Laoag City, during
his/her on-the-job training at the
_________________________________________________________________,
from ___________________, 202__ to _______________________, 202__, in
partial fulfillment of the requirements for the degree of Bachelor of Science in
Industrial Technology major in Food Technology.

Attested by:

_________________________
Training Supervisor
Signature of over Printed Name

RAYMUND R. BANIAGA
SIP Coordinator
MMSU-CIT, Laoag City
 ___________________________________________
___________________________________________
___________________________________________
Name and Address of Agency

_____________
(Date)
ADMIN (01-01-S19)
COMMENDATION

TO : ________________________________________________________
Name of Trainee

SUBJECT : LETTER OF COMMENDATION

1. I am pleased to commend you for your splendid and meritorious achievement in the
performance of your On-The-Job Training from ______________ to ___________
202__.

2. I have noted with full satisfaction of your professional competence, knowledge, and
devotion to your task and as well as to our diligence and sense of responsibility in
carrying out your assigned tasks thereby contributed immensely in accomplishing
the Company mission.

3. I, therefore, urge you to continue with more zeal and dedication to perform your task
in order to discharge your duty and responsibility, continue and carry on the good
work.

4. This commendation will form part of your personal file.

For the Administration:

By:

__________________________
(HR Officer) For the Office of the President/GM

____________________________
(President/General Manager)

___________________________________________
 ___________________________________________
___________________________________________
Name and Address of Agency

Date : _______________________
Assigned Dept. : _______________________

SUBJECT : CLEARANCE

This is to certify that as per available record, __________________________________,

On-The-Job Trainee, whose signature appears below, has no financial nor custodial obligations
with the company, insofar as the below-mentioned office are concerned.

This CLEARANCE is being issued in connection with subject for SEPARATION DUE
TO FINISHED THE REQUIRED NUMBER OF HOURS – accrued _____________________,
(No. of Hours Finished in Figures)
_________________________________________________, from the company of
employment
(No. of Hours Finished in Words)
effective _________________________.
(Date Released)

___________________________________ ___________________________________
On-The-Job Trainee President/General Manager

CLEARING OFFICERS: QUITCLAIM

I hereby agree and promise to pay the
company for any remaining accountability that I
_______________________________
Tool Keeper may have incurred during the period of my
employment.
_______________________________ This undertaking also serves as a waiver to
Head Technician
hold,
________________________________________
_______________________________ (Name of Trainee)
Accounting
harmless from any further claims or suits
whatsoever arising out of or as result of my
_______________________________
employment with this company, including exit
medical examination.
_______________________________ ________________________________

Employee
TABLE OF CONTENTS
Preliminaries
Title Page i
Approval Sheet ii
Letter of Commendation iii
OJT Clearance from the Company iv
Table of Contents v
Trainee’s Information vi
Rationale and Objectives of OJT vii
Why Automotive Technology? viii

Worksheets and OJT Training Activities

General Worksheet 1- Orientation and Getting to Know the Industry 1
General Worksheet 2- Occupational and Health Safety Practices,
Tools and Equipment in the Industry 9
General Worksheet 3- Technical and Industrial Applications:
Getting Acquainted with the Technical Personnel 12

Appendices
About the Industry
Dedication
Acknowledgment
Certificates
OJT Monitoring Form
Supervisor Interview Sheet
OJT Training Program
Photo Narrations
Conclusions and Recommendations
Evaluation Sheets
Daily Time Record

Trainee’s Biography
 ON-THE-JOB TRAINING WORKBOOK
Trainee Details

NAME OF STUDENT : ____________________________________________

SCHOOL : ____________________________________________

COURSE : ___________________________________________

SPECIALIZATION : ___________________________________________

YEAR LEVEL : ___________________________________________

NAME OF COMPANY : ____________________________________________

ADDRESS OF COMPANY : ____________________________________________

DATE STARTED : ____________________________________________

DATE FINISHED : ____________________________________________

TRAINING HOURS : ___________________________________________

------------------------------------------------------------

This workbook must be properly filled and submitted to the OJT Coordinator
immediately after the On-The-Job Training.

Corrected by: ____________________________ Signature: ___________________

(Printed Name)

Received by: ____RAYMUND R. BANIAGA______ Date Submitted: ______________

(OJT Coordinator)
 THE ON-THE-JOB TRAINING PROGRAM

Rationale

Through the on-the-job program the trainee, as an employee, receives

supervised training combined with updated and related technical instruction. The
program also provides the technical knowledge required to perform at a highly
skilled level and industry standard competency.

Goals/Objectives of On-the-Job Training

(Bachelor in Automotive Technology)

 To help prospective employers by matching the skill and competency

requirements of their jobs to the job/skills of future employees.

 To help trainees gain entry-level skills, dependable work habits, attitudes and
values by working in a real work environment.

 To encourage prospective employers and program trainees to develop a long-

term working relationship.

 To provide program trainees and future employers with vocational and support
services.

Why Food Technology?

A Condensed Review of Facts on Food Technology
(https://www.ift.org/career-development/learn-about-food-science/food-facts/about-fs)

Food technology is the application of food science to the selection, preservation,

processing, packaging, distribution, and use of safe food.

Related fields include analytical chemistry, biotechnology, engineering, nutrition,

quality control, and food safety management.

Food science is the study of the physical, biological, and chemical makeup of food; the
causes of food deterioration; and the concepts underlying food processing.

Food scientists and technologists apply scientific disciplines including chemistry,

engineering, microbiology, and nutrition to the study of food to improve the safety, nutrition,
wholesomeness and availability of food.

Depending on their area of specialization, food scientists may develop ways to process,
preserve, package, and/or store food according to industry and government specifications and
regulations.

Pursuing food technology as a career can be a lucrative opportunity for those who have
a passion for foods and innovation. Hence, they start with industrial immersion 1 and then the
second and final immersion for holistic development in preparing them for the food industry.

General Worksheet 1
Orientation and Getting to
Know the Industry
 Learning Outcomes:
At the end of the first month, you
are expected to have a higher level
of understanding and appreciation
of the following:

LO1. Familiarization of the industry.

LO2. Establish good social relations.
LO3. Appreciate the field of
specialization through industry
immersion.

Developing Higher Technical Thinking

Create a more meaningful OJT experience by engaging yourself in answering the
following questions.
 1. How familiar are you with the food industry where you will be immersed?
When we go to Robinson’s Mall, I always see Classic Savory, which I is one
______________________________________________________________________
of the most famous casual dining spots here in Ilocos. This is evident
______________________________________________________________________
because, whenever I’m at the mall, Classic Savory always has a lot of
______________________________________________________________________
customers, some of whom are willing to wait just to dine there.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. Describe the industry in terms of its services rendered to consumers.

Classic Savory provides good service. They uphold fairness by strictly
______________________________________________________________________
implementing the “first come, first served” rule. This applies to all
______________________________________________________________________
customers, regardless of whether they are loyal patrons or have
______________________________________________________________________
connections within the industry
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. How important is being familiar with the industry where you are engaged
with? What are some of its advantages?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Take a photo of your industry and paste it inside the box. Put a check if the industry where you are
deployed accounts to the given statements. If not, leave the space blank.
 _____ The working environment is safe here.
_____ Washroom and change area are accessible to all.
_____ It has good sanitation.
_____ Work area has a cool ventilation.
_____ There is tolerable amount of noise.
_____ It has toxic/hazardous elements/materials.
_____ Personnel are friendly.
_____ Managerial staff are friendly.
_____ There are numerous customers everyday.
_____ Time management is good.
_____ Products/services are of good quality.
_____ Employees are honest and dedicated.
_____ Skills are enhanced here.
_____ Rest period is provided for everyone.
_____ Overall, the industry is good.

Training Activities
Week 1

TRAINING ACTIVITIES
Trainee: ________________________________________________________
Genevieve J. Benito
Supervisor:_______________________________________________________
Dept./Section: _____________________ Supervisor’s Signature
_____________________

Date Activities
07/08/2024
_____________ We began the day with orientation, followed by heading to our designated
stations. I assisted the staff in preparing drinks and desserts for customers.
__________________________________________________________________
_____________ Additionally, I cleared and wiped the tables and swept the floor.
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

07/09/2024
_____________ I assisted the staff in preparing and serving drinks to customers at their tables.
Additionally, I took charge of making the pandan salad, supported the lobby
__________________________________________________________________
_____________ personnel in attending to customers, and even took on the role of receptionist for the
day.
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

07/10/2024
_____________ I learned how to input orders into the monitor, served drinks to customers, swept the
__________________________________________________________________
floor, cleared tables.
_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

07/12/2024
_____________ I learned how to take orders and familiarized myself with the menu. I then took
orders from customers, cleared and wiped tables, and even took on the role of a
__________________________________________________________________
_____________ receptionist.
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

07/13/2024 I took customers’ orders, input them into the monitor, cleared the table, dried the
_____________
utensils and plates, and set up the table.
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

07/14/2024 I prepared drinks for customers and delivered them to their tables. I also learned
_____________
how to mix fruit tea, swept the floor, and took orders.
__________________________________________________________________
 _____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

Remarks:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Training Activities
Week 2

TRAINING ACTIVITIES
Trainee: ________________________________________________________
Genevieve J. Benito
Supervisor:_______________________________________________________
Dept./Section: _____________________ Supervisor’s Signature
________________

Date Activities
07/15/2024 I took customers’ orders, inputted them into the monitor, cleared the tables, wiped
_____________
down the utensils and plates, set up the tables, swept the floor, and I assigned at the
__________________________________________________________________
_____________ reception.
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

07/16/2024 I arranged the table, prepared and served drinks to customers, assisted guests to
_____________
__________________________________________________________________
their tables, cleared and dried the utensils and plates, set up tables, and also swept
_____________ the floor.
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________
 07/18/2024
_____________ I wiped the utensils and plates, served customers drinks, arranged tables, guided
guest to their tables, and swept the floor.
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

07/19/2024
_____________ I took customers’ orders, prepared desserts, cleared tables, swept the floor, and
dried the washed utensils and plates.
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

07/20/2024 I took customers’ orders, set up the table, swept the floor, cleared and cleaned the
_____________
__________________________________________________________________
table, wiped down the plates and utensils.
_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

07/21/2024 I prepared drinks for customers and delivered them to their tables. I took customers’
_____________
orders, set up the table, dried the washed utensils and plates. I also took the role of
__________________________________________________________________
_____________ receptionist for the day
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________

Remarks:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
 Training Activities
Week 3
TRAINING ACTIVITIES
Trainee: ________________________________________________________
Supervisor:_______________________________________________________
Dept./Section: _____________________ Supervisor’s Signature _______________

Date Activities
_____________
__________________________________________________________________
_____________
__________________________________________________________________
_____________
__________________________________________________________________
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__________________________________________________________________

_____________
__________________________________________________________________
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 _____________ ________________________________________________________________

Remarks:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

General Worksheet 2
Occupational and Health Safety
Practices, Tools and Equipment in the
Industry

Learning Outcomes:
At the end of the second month,
you are expected to have a higher
level of understanding and
appreciation of the following:

LO1. Appropriate occupational and health

safety practices in the industry.
LO2. Familiarize with the different tools and
equipment used in the industry.
LO3. Appreciate the field of specialization
through industry immersion.
 Developing Higher Technical Thinking
Create a more meaningful OJT experience by engaging yourself in answering the
following questions.

1. Is proper sanitation protocol practiced in the industry in which you are engaged with?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. What specific safety measures are practiced evidently by the industry? You
may enumerate them.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. Is it important to practice safety measures in the workplace? Why?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
 ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Tools and equipment used in the industry. Place a sample photo in the boxes provided. One
industrial tool/equipment per box. Provide a brief description of each.

___________________________________ __________________________________
Name Name
___________________________________ __________________________________
___________________________________ __________________________________
___________________________________ __________________________________
___________________________________ __________________________________
___________________________________ __________________________________

___________________________________ __________________________________
Name Name
___________________________________ __________________________________
___________________________________ __________________________________
___________________________________ __________________________________
___________________________________ __________________________________
___________________________________ __________________________________

Training Activities
Week 4

TRAINING ACTIVITIES
Trainee: _______________________________________________________
Supervisor:______________________________________________________
Dept./Section: _____________________ Supervisor’s Signature ______________

Date Activities
_____________ _________________________________________________________________
_____________ _________________________________________________________________
_____________ _________________________________________________________________
_____________ _________________________________________________________________

_____________ _________________________________________________________________
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_____________ _________________________________________________________________

_____________ _________________________________________________________________
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_____________ _________________________________________________________________
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_____________ _________________________________________________________________
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_____________ _________________________________________________________________
_____________ _________________________________________________________________
_____________ _________________________________________________________________
_____________ _________________________________________________________________
Remarks:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Training Activities
Week 5

TRAINING ACTIVITIES
Trainee: _______________________________________________________
Supervisor:______________________________________________________
Dept./Section: _____________________ Supervisor’s Signature ______________

Date Activities
_____________ ________________________________________________________________
_____________ ________________________________________________________________
_____________ ________________________________________________________________
_____________ ________________________________________________________________

_____________ ________________________________________________________________
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_____________ ________________________________________________________________
_____________ ________________________________________________________________
_____________ ________________________________________________________________
_____________ ________________________________________________________________
Remarks:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Training Activities
Week 6

TRAINING ACTIVITIES
Trainee: _______________________________________________________
Supervisor:______________________________________________________
Dept./Section: _____________________ Supervisor’s Signature ______________

Date Activities
_____________ _________________________________________________________________
_____________ _________________________________________________________________
_____________ _________________________________________________________________
_____________ _________________________________________________________________

_____________ _________________________________________________________________
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Remarks:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

General Worksheet 3
Technical and Industrial Applications:
Getting Acquainted with the Technical Personnel

Learning Outcomes:
At the end of the third month, you
are expected to have a higher level
of understanding and appreciation
of the following:

LO1. Create a wider array of

understanding of the technical skills
needed in the industry.
LO2. Establish a more productive self
through enhancing technical skills
applications and advancements with
the technical personnel.
 Developing Higher Technical Thinking
Create a more meaningful OJT experience by engaging yourself in answering the
following questions.

1. How important is the development of technical skill in line with the skills needed in
the industry you are assigned?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

2. What possible advantages can you identify if there is camaraderie between

you as an apprentice and the technical personnel in the industry?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

3. What technical skills are expected from technical personnel in the industry
where you are deployed which can be of great help for you in the future?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
 Training Activities
Week 7

TRAINING ACTIVITIES
Trainee: _______________________________________________________
Supervisor:______________________________________________________
Dept./Section: _____________________ Supervisor’s Signature ______________

Date Activities
_____________ __________________________________________________________
_____________ __________________________________________________________
_____________ __________________________________________________________
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_____________ __________________________________________________________
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Remarks:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Training Activities
Week 8

TRAINING ACTIVITIES
Trainee: _______________________________________________________
Supervisor:______________________________________________________
Dept./Section: _____________________ Supervisor’s Signature ______________

Date Activities
_____________ _________________________________________________________________
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Remarks:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

APPENDICES
 About the Industry

Make a short description of the industry (its history, location, operations, etc.).
Use the space provided below.
Acknowledgment & Dedication
 Photo Narration- Week 1 & 2

Learning Insights:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Photo Narration- Week 3 & 4

Learning Insights:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 Photo Narration- Week 5 & 6

Learning Insights:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 Photo Narration- Week 7 & 8

Learning Insights:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
 Conclusions and Recommendations

Conclusions

Recommendations
 ON-THE-JOB TRAINING PERFORMANCE EVALUATION
Name: _____________________________________________ Age: ______ Sex: ______
Course: _________________________ Inclusive Dates of OJT: ________________________
Name of Industry: ____________________________________________________________
Address of Industry: __________________________________________________________

To the Rater/Trainer: Please indicate the rating for each applicable item by
encircling the appropriate number using the rating scale indicated herewith:

I. OBSERVABLE BEHAVIOR (50%)

Failure Poor Fair Good Excellent
1. Attendance and punctuality 1 2 3 4 5
2. Work habits and attitudes 1 2 3 4 5
3. Quality of work 1 2 3 4 5
4. Comprehension 1 2 3 4 5
5. Safety 1 2 3 4 5
6. Honesty and dependability 1 2 3 4 5
7. Judgment 1 2 3 4 5
8. Cooperation 1 2 3 4 5
9. Relationship with co-trainees 1 2 3 4 5
10. Relationship with supervisor 1 2 3 4 5
11. Emotional stability 1 2 3 4 5
12. Leadership 1 2 3 4 5

Total = __________________________
Average (OB) = _______

II. SKILLS (50%)

The following are the skills/tasks the trainee has performed in the training station,
which are related to the establishment’s operation and maintenance. (Please attach
additional sheets if necessary).
Failure Poor Fair Good Excellent
1. Knowledge of work and duties 1 2 3 4 5
2. Mastery of manipulative skills 1 2 3 4 5
3. Ability to adopt remedies 1 2 3 4 5
4. Ability to plan solution 1 2 3 4 5
5. Ability to motivate co-trainees 1 2 3 4 5
6. Ability to work independently 1 2 3 4 5
7. Ability to solve minor problems 1 2 3 4 5
8. Ability to perform assignment 1 2 3 4 5
9. Safety to practices, consciousness 1 2 3 4 5
10. Maintenance of order and discipline 1 2 3 4 5
11. Use and care of tools and equipment 1 2 3 4 5
12. Accomplishment and housekeeping 1 2 3 4 5

Total (Skills) = ________________________________

LEGEND:
OB + Skills
5.0 1.00 Excellent Final Grade ____________
4.7 – 4.9 1.25 Very Outstanding __________

4.4 – 4.6 1.50 Outstanding

4.0 – 4.3 1.75 Very Good
3.7 – 3.9 2.00 Good
3.4 – 3.6 2.25 Very Satisfactory
3.0 – 3.3 2.50 Satisfactory
2.7 – 2.9 2.75 Fair
2.4 – 2.6 3.00 Passed
2.0 – 2.3 3.50 Poor
1.7 – 1.9 4.00 Very poor
1.0 – 1.6 5.00 Failed
Rated by:

_________________________________
On-The-Job Trainor
Signature over Printed Name
Approved:

_________________________________
Division Chief
Signature over Printed Name
 DAILY TIME RECORD
Name: ____________________________________________________________________________
For the Month of ___________________
Official Hours of Arrival and Departure _________________________________

Day A.M. P.M. Undertime

Arrival Departure Arrival Departure Hours Minutes
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I certify on my honor that the above is a true and correct report of the hours of work
performed, record of which was made daily at the time of arrival at and departure from the office.
_____________________________
Signature

Verified as to the prescribed office hours ____________________________

In Charge
 DAILY TIME RECORD
Name: ____________________________________________________________________________
For the Month of ___________________
Official Hours of Arrival and Departure _________________________________

Day A.M. P.M. Undertime

Arrival Departure Arrival Departure Hours Minutes
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I certify on my honor that the above is a true and correct report of the hours of work
performed, record of which was made daily at the time of arrival at and departure from the office.
_____________________________
Signature

Verified as to the prescribed office hours ____________________________

In Charge
MMSU College of Industrial Technology
MARIANO MARCOS OFFICE OF THE OJT COORDINATOR
STATE UNIVERSITY

Personal Information Data Sheet

I.D.
Name: _________________________________________________
Photo
Home Address: _______________________________________________
Address while on OJT: _________________________________________ 2”X2”
Date of Birth:___________________ Place of Birth:_______________________
Sex:____________ Age:_______________ Civil Status:___________________
CP/ Tel. #_______________________________ Email: ____________________
Citizenship: _____________________________ Religion: __________________
Father’s Name: __________________________ Occupation: _______________
Mother’s Name: _________________________ Occupation: _______________

EDUCATIONAL BACKGROUND

School Address Inclusive Dates

Elementary ____________________________________________________________
Secondary ___________________________________________________________________
College ___________________________________________________________________
Course:_______________________________________________________________________
Major________________________________________________________________________

PREVIOUS TRAINING/WORK EXPERIENCE:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

CHARACTER REFERENCES:
Name Occupation Address
1. __________________________________________________________________________
2. __________________________________________________________________________
3. __________________________________________________________________________

I certify that the above statement is true and correct to the best of my knowledge and belief.

___________________________
Signature