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Nurses' Application Form by PRC

Nurses' Application Form by PRC

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Published by NURSETOPNOTCHER
PRC Form for Nursing Licensure Examination
PRC Form for Nursing Licensure Examination

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Categories:Types, Legal forms
Published by: NURSETOPNOTCHER on Mar 12, 2010
Copyright:Attribution Non-commercial

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04/16/2011

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Republic of the Philippines
Professional Regulation CommissionProfessional Regulation CommissionProfessional Regulation CommissionProfessional Regulation CommissionProfessional Regulation Commission
Manila
PRC App Form No. 001-A(Sept 2007)
1ST TIMER (NEW)REPEATERCONDITIONED
WARNING: All documents/statements submitted are subject to verification and any false statement or misrepresentation madein this application is a ground for disqualification and criminal prosecution/administrative sanction for falsification
Part I - PERSONAL INFORMATION
SURNAMEGIVEN NAME MIDDLE NAME M.I.MALEFEMALECITIZENSHIPCOMPLETE MAILING ADDRESS (House No., Street, Town Prov./City)Town/City/ProvRURBAN CODEZIP CODESINGLE WIDOW/ER MARRIED ANNULLEDDIVORCED LEGALLY SEPARATEDDATE OF BIRTH
(mm/dd/yyyy)
PLACE OF BIRTH (City, Town Province)Town/City/ProvRURBAN CODESPOUSES NAME & CITIZENSHIP FATHERS NAME & CITIZENSHIP MOTHERS NAME & CITIZENSHIPHAVE YOU EVER BEEN CONVICTED IN A FINAL JUDGMENT BY ANY COURT, MILITARY TRIBUNAL OR ADMINISTRATIVE BODY?
Part II – EDUCATIONAL INFORMATION
REVIEW SCHOOL/CENTER ATTENDED
Part III – PREVIOUS NURSES’ LICENSURE EXAMINATION/S TAKEN
1.) EXAMINATION TYPE (EX CODE)
I HEREBY CERTIFY that the information and/orstatements in this application including the exhibits submitted insupport thereof are all true and correct of my own knowledge,and that I am fully aware that any false information or statementin this application or in its attachments shall render me liable forcriminal prosecution and /or administrative sanction.I AM WILLING TO TAKE A VALIDATING EXAMINATIONIN CASE THE TEST RESULTS IN MY PLACE OF EXAMINATION ARESTATISTICALLY IMPRORABLE.
RIGHT THUMBMARK 
2.) NUMBER of TIMES TAKEN (NX CODE) ACTION TAKENBY THE CASH SECTION
 APPLICATION & QUALIFICATION EVALUATION DIVISION
E-mail AddressLandline and Mobile No.
(include area code)
Paste here your recentpassport size picturewith COMPLETE Name Tagin plain white backgroundScanned/Photocopiedpicture not accepted
DEGREE/COURSE OBTAINEDNAME of SCHOOL ADDRESS/LOCATION of SCHOOLPRC SCHOOL CODEPRC COURSE CODEDATE GRADUATED
(mm/dd/yy)
PRC BOARD CODE
B. S. Nursing40182600
OTHER EDUCATIONAL ATTAINMENT1stNAME of SCHOOLDATE GRADUATED
(mm/dd/yyyy)
 ADDRESS/LOCATION of SCHOOL2nd3rd
NURSES’ APPLICA NURSES’ APPLICA NURSES’ APPLICA NURSES’ APPLICA NURSES’ APPLICA TION FORM (NAF)TION FORM (NAF)TION FORM (NAF)TION FORM (NAF)TION FORM (NAF)
NAME of EXAMINATIONDATE TAKENRATINGPASSEDRESULT OF EXAMINATION (
Pls. check 
)FAILEDCOND.EXAM NO VERIFIED BY 
Degree/Course 
prior to BS Nursing 
Subscribed and sworn
to before me this _________ day of __________________ 20_____ at ______________. Affiant applicant exhibited to me his/her Community TaxCertificate No. _______________________ issued at ________________________ on __________________.
 ___________________________ 
Signature 
 ___________________________ 
Date 
MeteredDocumentaryStamp
 ACTION TAKENBY THE APPLICATION PROCESSOR Processed by: _______________________ Date:_______________________________ Remarks: ___________________________  ___________________________________  ACTION TAKENBY THE LEGAL DIVISION/OFFICER Processed by: _____________________ Date:_____________________________ Remarks: ________________________ _________________________________  Amount: ___________________________ O.R. No:____________________________ Date: _____________________________ Issued by: __________________________  ACTION TAKENBY THE BOARDChairman: _______________________Member:__________________________ Member:__________________________ Remarks: _________________________ Issued by: _______________________ Date:_____________________________ Remarks: _________________________  __________________________________ PRC Administering Officer ACTION TAKENBY THE ISSUING OFFICER 
Regular B.S. Nursing With Other Degree/s
PRC SCHOOL CODE
STATUS CODES
(
refer at the back) : 
PLACE of EXAM
 Application No
.
 __________________ 
NOT FOR SALE
This Form is pre-numbered
REPRODUCTIONIS NOT ALLOWED
print this form using LASER or INKJET printerhaving BEST or NORMAL print setting & FITTO PAPER in 8.5 x 14 (legal size) paper
Date of ExaminationPlace of Examination
PERRC No.
 _____________ 
 YES
(If yes, attach hereto a copy of the decision)
NO

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