APPLICATION FORM - Professional Regulation Commission

1 Republic of the PhilippinesPROFESSIONAL Regulation COMMISSIONM anilaNOTICE : This APPLICATION must be filled out in INK and in the applicant s handwriting. All supporting documents shall become part ofthe records of the Commiss ion. All applic ations must be f iled PER SONAL LY by the FORMN O T F O R S A L EPaste here yourrecentpassport size picturewith COMPLETEName Tagin plain whitebackgroundScanned/Photocopiedpictur e not acceptedFirst TimerRepeaterConditionedSURNAMEGIVEN NAME/SMIDDLE NAMEM aiden Surname (for married female only)GenderMaleFemaleSingleMarriedWidow/ erCitizenship HAVE YOU EVER BEEN CHARGED AND CONVICTED BY FINAL JUDGEMENT BY ANY COURT OF JUSTICE/MILITARY TRIBUNAL ORADMINISTRATIVE BODY?Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, )Contact Numbers (Landline & Mobile)Name of SchoolAddress/Location of SchoolPRC School CodeDegree/Course ObtainedPRC COURSE CodePRC Board CodeDate Graduated (mm/dd/yy)Place ofExaminationDate Taken(mm/yy)RatingPassedResult of Examination (pls check) byI HEREBY CERTIFY that the information and/orstatem ents in th is applic ation includ in g the supp ortingdocuments submitted in support thereof are all true andcorrect of my own knowledge, and that I am fully aware thatany false information or statement in this APPLICATION or in itsattachments shall render me liable for criminal prosecutionand /or administrative ADMINISTERING OFFICERACTION TAKEN BY THE APPLICATION PROCESSORNOTICE OF ADMISSION(NOA)ISSUANCE of the FOLLOW ING FORMSPERMANENT EXAMINATION & registration RECORD CARD (PERRC)REMARKSPRC form No.

2 001(Revised September 2010)Z ip CodeApplication Code (Town/City, Prov)Spouse s Name & CitizenshipFather s Name & CitizenshipMother s Name & CitizenshipOther Higher Educational AttainmentName of SchoolPART III - PREVIOUS PRC LICENSURE EXAMINATION/S TAKEN (Last Three Exams)Name of ExaminationExam NoPROCESSORA bsentName of ExaminationDate of ExaminationPlace of ExaminationDate of Birth (mm/dd/yy)Place of Birth (City/Town,Prov.)NoYes (If yes, attach hereto a copy of the decision)PART II -EDUCATIONAL INFORMATIONA ddress/Location of SchoolRIGHT THUMBMARKS ignature of ApplicantDate AccomplishedSubscribed and sworn to before m e this _____ day of_____ 20_____ at _____. Affiant applicant exhibitedto me his/her Community Tax Certificate issued at _____on of Oath is FREE(Office Order & 2009-379both dated September 3, 2009)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 READ THE REQUIREMENTS, STEPS and OTHER REMINDERS at the BACKDateACTION TAKEN BY THE LEGAL OFFICER (if applicable)LEGAL OFFICERREMARKSDateACTION TAKEN BY THE BOARDAPPROVEDDISAPPROVEDCONDITIONALCHAIR MAN/MEMBERREMARKSDateACTION TAKEN BY THE CASHIEROFFICIAL RECEIPT PAIDDateACTION TAKEN BY THE ISSUING OFFICERREMARKSISSUING OFFICERDateDate (mm/dd/yy)REPRODUCTIONIS ALLOWEDF ilipinoOthersCivil StatusPART I -PERSONAL INFORMATION_____PRC SCHOOLCodeDate Graduated(mm/dd/yy)STATUS CODES (refer at the back)Review School/Center1.

3 Examination Type (EX Code)2.) Number of Times Taken (NX Code)Self-ReviewSchool-Based ReviewOthers (specify name)RURBAN Code (Town/City, Prov)E-mail Add ressPRC Central Office : APPLICATION DIVISION P. Paredes St., Sampaloc 1008 Manila, PhilippinesWebsite : No.: (63-2) - 314-00-27I M P O R T A N T1. Keep and bring your Notice of Admission with Official Bring pencils (No. 1 or 2), ballpen (with black ink only), one piece (1) big brown envelope, one long transparentplastic Report to your school assignment before 6:30 a. m. on examination days. Late examinees will not be will mean forfeiture of examination DO NOT BRING HOME THIS APPLICATION form . This form MUST BE ACCOMPLISHED & SUBMITTED to theApplication Division in order for your name to be included in the List of OF REQUIREMENTS (ORIGINAL and PHOTOCOPY)NSO Birth CertificateNSO Marriage Contract (female married applicant)Transcript of Records with degree/course, exact date of graduation , SpecialOrder ( )/exemption/accreditation/deregulation status, SCANNEDPICTURE and remarks FOR BOARD EXAMINATION PURPOSES ONLY Four (4) pcs Passport Size (1 1/2 x 1 1/2) colored pictures with full name tagCommunity Tax Certificate (cedula)Any valid IDENTIFICATION CARDA ffidavit of Competency (CPM)Certificate of registration /PRC License (Nurse-Midwife, Ocular Pharm)Certificate of 1,000 Case Hours (Social Worker)Certificate of Experience (CPM, Env tal Planner, Landscape Arch, MasterPlumber)Cerificate of Special Pharmacology Course (Ocular Pharmacology)

4 Certificate of Employment (CPM, Env tal Planner, Landscape Arch, MasterPlumber)Certificate of Internship/OJT (Physician, Pharm, PT & OT, Dental Tech &Hygienist)*Certification of Good Moral Character [Agri (2), Crim (3), Fishery Tech (1),Forester (2), Lib.(2), Env tal P. (1)]Certification of Mine and Mill Practice (Mining Engineer)Copy of Thesis - Title Page & Approval Sheet (Chemist)STEP 1: Secure APPLICATION form at the Public Assistance Counter or download from 2: Fill-out APPLICATION form then proceed to Customer Service Center for documentary stamp and CoopStore for the window mailing envelope with postage 3: Processing Counters (windows 5,6,7,8) or other designated counters for evaluation and assessment .STEP 4: Pay examination fee at the Cashier s Counters (windows 1,2,3,4) or other designated 5: Accomplish the Permanent Examination and registration and Record Card (PERRC) and Notice ofAdmission (NOA).STEP 6: SUBMIT ALL DOCUMENTS at the Issuance Counters (windows 9,10,11,12) or other 7: Verify your school assignment at the PRC Office or visit 2-3 working days before thefirst day of exam.

5 STEPS in APPLYING for LICENSURE EXAMINATION1. Refer to the MASTERLIST of ADDRESS/RURBAN CODES posted at the premises of the filing center for the CODES of the Town, City or Province of your Residence and Postal Address and Place of Birth . This is different from the ZIP Refer to the MASTERLIST of SCHOOL CODES also posted at the filing center for the School /College/University and Location3. Refer to the MASTERLIST of COURSE CODES for the Course For STATUS CODES, use the following:a. EX CODE - Examination Type CodePrint 1 for Complete/First TimerPrint 4 for Theory OnlyPrint 7 for FinalsPrint 2 for RepeatersPrint 5 for Practical OnlyPrint 8 for Finals with PrelimsPrint 3 for Removal/ConditionedPrint 6 for Prelimsb. NX CODE - Number of Times TakenPrint 0 for NonePrint 1 for OncePrint 2 for and so onRURBAN CODES/SCHOOL CODES/COURSE CODES/BOARD CODES/STATUS CODESD aily Time Record (Pharmacist)Detailed Description of Equipment (CPM)Diploma, Logbook, Mentor s PRC License,PTR & IAPOA (Architect)High School Diploma (RME)NBI Clearance (Arch, Chem Eng, CPA,Criminologist, Dentist, Dental Hygienist,Dental Technician, Vet Med, Guidance &Counselling)Police & Court Clearances (Criminologist)Record of Deliveries Handled (Midwife)Record of OR-DR Cases (Nurse)Refresher Course (CPA, Dentist, Med TechPT & OT, Physician, Pharm, Opto)Summary of Related Learning ExperienceOthersNO applications SHALL BE ACCEPTED AFTER THE DEADLINEfor BLURRED NSO Birth Cert/MarriageCertificate.

6 It MUST BE SUPPORTED BY theLOCAL CIVIL REGISTRY Birth Certificateand Marriage form No. 001 (Revised September 2010)O-LIC/APPLICCHED Permit/ Recognition for NewSchools and / or New Programs*Certification of Good Moral Character - must come from any and/or all of the follow ing :Barangay, Church, School, and Employer