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F-OJT-02

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PICTURE

PERSONAL DATA SHEET

Name: Jan Four G. Dongallo Student No.: 1501044

Address: 035 Igualdad Street, Calaca , Batangas

Course: BS Civil Engineering

Major: Civil Engineering OJT hours: 240 hrs

Contact no. (landline): None (cellular): 09068597086

Person to notify in case of emergency: Bibiana G. Dongallo

Relationship: Mother Contact no.: 09668213969

COMPANY INFORMATION

Name of Company: Contact No.:

Address of Company:

Contact Person: Position:

CONFORME: By signing below, I hereby voluntarily waive any and all rights I may have to privacy and/or confidentiality
pertaining to the above-mentioned purposes insofar as the information is released solely to the authorized persons in
accordance thereto.

________________________________
Signature over Printed Name

____________________
Date Signed

Revision No.: 2 Campuses: Hilltop | MH del Pilar | Pallocan East | Pallocan West | Lipa
Issue Date: August 24, 2018 Telephone Numbers: +63 43 723 1446 | 980 0041
Revision Date: August 20, 2018 Website: www.ub.edu.ph

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