Reference No.: BatStateU-FO-OJT-02 Effectivity Date: May 18, 2022 Revision No.

: 02

STUDENT TRAINEE’S PERSONAL HISTORY STATEMENT

Student Information

NAME: MAGPANTAY JOSUA BALMES

LAST FIRST MIDDLE

AGE: 22 SEX: / MALE

☐ ☐ FEMALE

HEIGHT: 5’4 WEIGHT:48 kgs. COMPLEXION:

DISABILITY (IF ANY)

BIRTHDATE: BIRTHPLACE: CANDELARIA, QUEZON

0 1 1 7 0 0

m m d d y y

CITIZENSHIP: FILIPINO CIVIL STATUS: SINGLE

PRESENT ADDRESS: SITIO GULOD BRGY. MASALUKOT IV CANDELARIA, QUEZON TEL. NO. 09560934153

PROVINCIAL ADDRESS: SITIO GULOD BRGY. MASALUKOT IV CANDELARIA, QUEZON TEL. NO. 09690273420

Family Background (if parents are deceased, give data for the nearest relative and indicate relationship to applicant)

FATHER’S NAME: JESSIE A. MAGPANTAY OCCUPATION: FARMER

MOTHER’S NAME: LUCIA B. MAGPANTAY OCCUPATION: HOUSEWIFE

PROVINCIAL ADDRESS: SITIO GULOD BRGY. MASALUKOT IV CANDELARIA, QUEZON TEL. NO.: 09555527412

GUARDIAN’S NAME: LUCIA B. MAGPANTAY TEL. NO.: 09555527412

SCHOOL INFORMATION
TH
PROGRAM: BS MECHANICAL ENGINEERING YEAR LEVEL: 5 YEAR

MAJOR: LENGTH OF PROGRAM: 4 YEARS

SCHOOL ADDRESS: GOLDEN COUNTRY DDDD HOMES ALANGILAN,

DEPARTMENT: COLLEGE OF ENGINEERING
BATANGAS CITY

OJT COORDINATOR: ENGR. LENDON S. ARCILLAS TEL. NO.:

OJT HEAD: TEL. NO.:

DEAN: Dr. REYNATO A. GAMBOA TEL. NO.:

In case of emergency, notify

NAME: LUCIA B. MAGPANTAY RELATIONSHIP: MOTHER

794 ACACIA ST. PAHINGA NORTE, CANDELARIA, QUEZON

ADDRESS: TEL. NO.: 09555527412

Pursuant to Republic Act No. 10173, also known as the Data Privacy Act of 2012, the Batangas State University, the National Engineering University, recognizes its commitment to protect and respect the
privacy of its customers and/or stakeholders and ensure that all information collected from them are all processed in accordance with the principles of transparency, legitimate purpose and proportionality
mandated under the Data Privacy Act of 2012.

I hereby certify that the foregoing answers are true and correct to the best to my knowledge, belief and ability.

Signed at: CANDELARIA, QUEZON Date: AUGUST 31, 2022

FFFFFF MAGPANTAY, JOSUA B FFFFFF

Applicant’s Signature over Printed Name