LAST NAME FIRST NAME MIDDLE NAME MIDDLE

INITIAL
Residence/Complete Mailing Address

Date of Birth (mm/dd/yy)

Place Of Birth (City/Town/Province)

Citizenship
Single Widow/er
Married Separated
Male
Female
Spouse’s Name and Citizenship
Father’s Name and Citizenship

Mother’s Name and Citizenship
School Attended/Location

Degree / Course Completed
Date Graduated (mm/yyyy)


EXAMINATION RECORD
(To be filled up by PRC)
Date Taken Rating P/F/Cond Exam No Recorded by (signature)
1.
2.
3.
4




















LAST NAME FIRST NAME MIDDLE NAME MIDDLE
INITIAL
Residence/Complete Mailing Address

Date of Birth (mm/dd/yy)

Place Of Birth (City/Town/Province)

Citizenship
Single Widow/er
Married Separated
Male
Female
Spouse’s Name and Citizenship
Father’s Name and Citizenship

Mother’s Name and Citizenship
School Attended/Location

Degree / Course Completed
Date Graduated (mm/yyyy)


EXAMINATION RECORD
(To be filled up by PRC)
Date Taken Rating P/F/Cond Exam No Recorded by (signature)
1.
2.
3.
4





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your recent
1 ½ x 1 ½
Colored picture with
Complete name tag
In plain white
background

IMPOSTOR WILL
BE PROSECUTED
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8l0080 0ß80
REMARKS / SUBJECTS TO BE TAKEN
(To be filled up by PRC)

Subj. 1. ___________________
Subj. 2. ___________________
Subj. 3. ___________________
Recorded by :

(Printed Name and Signature)
Subscribed and sworn to before this _______day of ___________ 20 ____ at _______________. Affiant applicant
exhibited to me his Community Tax Certificate No. _______________ issued at _______________ on
____________________.
__________________________________
PRC Administering Officer
I hereby certify that
all information that I
have written herein are
true and correct of my
own knowledge and
that I am fully aware
that any false
information renders me
liable for criminal
prosecution.
_______________
(Signature)




(Right Thumbmark)
(To be printed in BOLD letters personally by applicant)
PRC Form No.03 (Rev03/03/2004)
Deficiency Code : __________
Lifting Reference : __________
Entered by : ___________
NOT FOR SALE
REPRODUCTION NOT ALLOWED
PROFESSION / BOARD OF
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Paste here
your recent
1 ½ x 1 ½
Colored picture with
Complete name tag
In plain white
background

IMPOSTOR WILL
BE PROSECUTED
Fl8Nß8l81 lkßNl8ß1l08 ß80 8l6l$18ß1l08
8l0080 0ß80
REMARKS / SUBJECTS TO BE TAKEN
(To be filled up by PRC)

Subj. 1. ___________________
Subj. 2. ___________________
Subj. 3. ___________________
Recorded by :

(Printed Name and Signature)
Subscribed and sworn to before this _______day of ___________ 20 ____ at _______________. Affiant applicant
exhibited to me his Community Tax Certificate No. _______________ issued at _______________ on
____________________.
__________________________________
PRC Administering Officer
I hereby certify that
all information that I
have written herein are
true and correct of my
own knowledge and
that I am fully aware
that any false
information renders me
liable for criminal
prosecution.
_______________
(Signature)




(Right Thumbmark)
(To be printed in BOLD letters personally by applicant)
PRC Form No.03 (Rev03/03/2004)
Deficiency Code : __________
Lifting Reference : __________
Entered by : ___________
NOT FOR SALE
REPRODUCTION NOT ALLOWED
PROFESSION / BOARD OF
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8000f08. Fl0880 90fll¶ ¢f09l008 0K8Ml8. 108ßk ¶00. Ff09l008 Fl800 0l lK8M . ________________
Dummy PERRC Only
Dummy PERRC Only

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