I, ___________________________________ of legal age, Filipino citizen, single and

residing in ________________________________________, under oath hereby state:

1. That, I voluntarily agree to undergo practicum/ on-the-job training with

____________________________, as a requirement for graduation in the course
leading to the degree _________________________________ in University of Santo
Tomas Legazpi;

2. That, my practicum/ on –the- job training with the above- mentioned establishment is
with the consent of my parent/ guardian and the approval of the Dean of the College of
Engineering, Architecture and Fine Arts, as indicated by their respective signature
below;

3. That, I shall abide with all the applicable rules and regulations of the above-stated
establishment disclosed to me, otherwise my training therewith may be discontinued;

4. That, I shall faithfully comply with all training regulations, and satisfactorily complete the
requirements, of the practicum/ on-the-job training program;

5. That, no employer-employee relations shall arise from my training with the above stated
establishment; and

6. That, I shall be liable for all damages to property or injury to persons directly caused by
my intentional or negligent acts committed while in the course of the training subject,
however, to the requirements of due process.

Signed this _________________, 2019 in ____________________________, Philippines.

_____________________________

Student/ Trainee

With my consent: With my approval:

_______________________________ ___________________________________
(Signature over printed name) Dean, CEAFA
Parent/ Guardian

SUBSCRIBE AND SWORN to before me this __________________ in ____________________, Philippines by

above-named student/ trainee, who satisfactorily proved to me his/her identity by exhibiting ID
___________________________________________________________, and acknowledged that he executed the
same. Further, affiant exhibited to me his/her Community Tax Certificate No. __________, issued on
______________ in _______________________.

NOTARY PUBLIC
Doc. No. ____;
Page No. ____;
Book No. ____;
Series of 20___;