POLYTECHNIC UNIVERSITY OF THE PHILIPPINESCOLLEGE OF ENGINEERING AND ARCHITECTURE

DEPARTMENT OF ELECTRICAL ENGINEERING

NDC Compound, Sta. Mesa, Manila

WAIVER

KNOW ALL MEN BY THESE PRESENTS:

I, __________________________________, Filipino, ______ years of age, single/married. With residence at ____________________________________________________ and presently enrolled at the Polytechnic University of the Philippines, College of Engineering and Architecture, Sta. Mesa, Manila, hereby voluntarily renounce and waive, with the consent and conformity of my parents/guardian, all claims that I may have against Polytechnic University of the Philippines, and/or its officials, arising from any cause/s that may occur in connection with my On the Job Training at ________________________________________.

This waiver is valid only on the duration of the said On-the-Job Training.

IN WITNESS WHEREOF, I hereby affix my signature this _______ day of _________, ______ at ______________________________.

WITH MY CONSENT AND CONFORMITY:

______________________________________ ____________________________

Parent/Guardians signature over printed name

Signature of student

CTC NO.

Issued at

on ________________

________________

________________

SUBSCRIBED AND SWORN to before me, this _____ day of __________, ______, by ______________________________, who exhibited to me his Residence Certificate No. __________________

Issued at _________________________ on _______________________.

Notary Public

Until May 31, _______

PTR No. ________________

Doc. No. _____

Page No. _____

Book No. _____

Series of _____