Republic Of The Philippines Professional Regulation Commission Application Form (Prc Form No.001)
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1
2N O T F O R S A L E
PRC Form No. 001
Republic of the Philippines
(Revised September 2010)
PROFESSIONAL REGULATION COMMISSION
REPRODUCTION
IS ALLOWED
Application No.
Manila
PRC Central Office : APPLICATION DIVISION P. Paredes St., Sampaloc 1008 Manila, Philippines
Paste here your
Website :
Tel. No.: (63-2) - 314-00-27
recent
APPLICATION FORM
First Timer
passport size picture
with COMPLETE
Repeater
Name Tag
Conditioned
Name of Examination
in plain white
Absent
Date of Examination
background
Place of Examination
Date (mm/dd/yy)
Scanned/Photocopied
picture not accepted
NOTICE : This application must be filled out in INK and in the applicant’s handwriting. All supporting documents shall become part of
the
records
of
the
Commiss ion.
All
applic ations
must
be
f iled
PERSONALLY
by
the
applicant.
PART I -PERSONAL INFORMATION
MIDDLE NAME
SURNAME
GIVEN NAME/S
Maiden Surname
(for married female only)
Permanent Mailing Address
RURBAN Code
(House no., Street, Village/Subd., Brgy., Town, Prov./City)
Zip Code
(Town/City, Prov)
Gender
Citizenship
Contact Numbers (
)
E-mail Address
Landline & Mobile
Male
Female
__ __ __ __ __ __ __ __
Filipino
Others
RURBAN
Place of Birth
Date of Birth (mm/dd/yy)
(City/Town,Prov.)
Code (Town/City, Prov)
Civil Status
Single
Married
Widow/er
Father’s Name & Citizenship
Mother’s Name & Citizenship
Spouse’s Name & Citizenship
HAVE YOU EVER BEEN CHARGED AND CONVICTED BY FINAL JUDGEMENT BY ANY COURT OF JUSTICE/MILITARY TRIBUNAL OR
No
Yes
ADMINISTRATIVE BODY?
(If yes, attach hereto a copy of the decision)
PART II -EDUCATIONAL INFORMATION
PRC School Code
Address/Location of School
Name of School
Degree/Course Obtained
PRC Board Code
Date Graduated (mm/dd/yy)
PRC COURSE Code
PRC SCHOOL
Date Graduated
Address/Location of School
Other Higher Educational Attainment
Name of School
Code
(mm/dd/yy)
PART III - PREVIOUS PRC LICENSURE EXAMINATION/S TAKEN
(
)
Last Three Exams
Result of Examination (pls check)
Place of
Date Taken
Exam No
Name of Examination
Verified by
Rating
Examination
(mm/yy)
Passed
Failed
Cond
.
Self-Review
School-Based Review
Others (specify name)
Review School/Center
STATUS CODES (refer at the back)
1.) Examination Type (EX Code)
2.) Number of Times Taken (NX Code)
ACTION TAKEN BY THE APPLICATION PROCESSOR
I HEREBY CERTIFY that the information and/or
ISSUANCE of the FOLLOWING FORMS
statements in this application including the supporting
PERMANENT EXAMINATION &
NOTICE OF ADMISSION
documents submitted in support thereof are all true and
REGISTRATION RECORD CARD (PERRC)
(NOA)
correct of my own knowledge, and that I am fully aware that
any false information or statement in this application or in its
REMARKS
attachments shall render me liable for criminal prosecution
and /or administrative sanction.
PROCESSOR
Date
ACTION TAKEN BY THE LEGAL OFFICER (
)
if applicable
RIGHT THUMBMARK
REMARKS
Signature of Applicant
LEGAL OFFICER
Date
Date Accomplished
ACTION TAKEN BY THE BOARD
Subscribed and sworn to before me this __________ day of
APPROVED
DISAPPROVED
CONDITIONAL
_____________ 20_____ at ______________. Affiant applicant exhibited
REMARKS
to me his/her Community Tax Certificate No.
_______________________ issued at ________________________
CHAIRMAN/MEMBER
on __________________.
Date
ACTION TAKEN BY THE CASHIER
AMOUNT PAID
OFFICIAL RECEIPT NO.
Documentary
Date
CASHIER
ACTION TAKEN BY THE ISSUING OFFICER
Stamp
PRC ADMINISTERING OFFICER
REMARKS
Administration of Oath is FREE
(Office Order No.2009-377 & 2009-379
both dated September 3, 2009)
ISSUING OFFICER
Date
IMPORTANT
: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL MEAN NON -
INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF EXAMINATION FEES.
PLEASE READ THE REQUIREMENTS, STEPS and OTHER REMINDERS at the BACK
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