PRC APP Form No, 004 (Rev Sept 2007) THIS FORM IS Republic of the Philippines = NOT FOR SALE Professional Regulation intaga —— Commission your recent PASSPORT SIZE colored picture with complete NAME OF BOARD — APPLICATION FOR pee? REGISTRATION WITHOUT EXAMINATION PERSONAL DATA _ : a TAST NAME FIRST NAME ] MIDDLE NAME __ | CITIZENSHIP CIVIL STATUS, 7 DATE OF BIRTHmmiddiyy) Clwate Cl remate Lsncte Carrie Oo _ [winoweo [7] serarareo | PERMANENT MAILING ADDRESS ZIP CODE PLACE OF BIRTH a TELEPHONE /CELL PHONE NC i ‘SPOUSE'S NAME & CITIZENSHIP | FATHER'S NAME & CITIZENSHIP MOTHER'S NAME & CITIZENSHIP Have you ever been convicted in a jadgment before any cour, miltary Wbunal or administrative body? [] YES LINO (ifyes, please attach a copy of the decision) EDUCATIONAL DATA | Name of School Location: Course/Degree FROM | TO | Completed (rnmidaiyy) | (eemicaiyy) | Vocational | 1 College 1 - Graduate/Post | Graduate | PREVIOUS LICENSURE EXAMINATION/S TAKEN T ‘VERIFIED BY PRCID | NAME OF EXAMINATION | DATETAKEN | Record Section Registration Division | YEAR EXPIRED l _ - EMPLOYMENT RECORD _ FROM To) OFFICE POSITION HELD SPECIFIC WORK/FUNCTION | (mmi/dd/yy) | (mm/dd/yy) I | ‘ACTION TAKEN CHAIRMAN MEMBER MEMBER MEMBER MEMBER Remarks Processed by: Date: "ACTION TAKEN BY THE BOARD ACTION TAKEN BY CASHIER Date: Issued ‘Subseribed and sworn to before this. applicant exhibited to me his Community Tax ay of Cerificate No. PRE ADMINS | HEREBY CERTIFY that the Information and/or ‘statements In this application Including the documents ‘submnitted in support thereof are all true and correct to my ‘own knowledge, and that | am fully aware that any false Information or’ statement In this application in this attachments shall render me liable for criminal ‘prosecution and /or administrative sanction. ‘Applicant's Signature ‘THUMBMARK Date Accomplished TERING OFFICER LR. No. REGISTRATION WITHOUT EXAMINATION ‘Amount Paid: FOLLOW-UP SLIP Date Paid : NAME: PROFESSION: DATE OF FILING: Please verify approval of your application and resolution number at the Office of the Asst. Secretary @ (02) 735-1533 after 3 months.STEPS IN FILING APPLICATION FOR REGISTRATION WITHOUT EXAMINATION } PAaCN = Fill-out application form together with required documents for re-evaluation to the Office of the Asst. Secretary (3° Fir, Main Bldg.) at the PRC Central Office and Regional Offices processing counters, Go to the Legal Division (2™ Fir, Main Bldg) for notarization Go to the cashier for payment of fees. (Ground Fir, Main Bldg.) Go to the Customer Service Center for documentary stamp (Ground Fir., Annex Bldg.) ‘Submit duly accomplish application form to the Office ofthe Asst, Secretary. Aer three (3) months, verify status of application at Tel. No. (02) 735-1533, DOCUMENTS REQUIRED (CERTIFIED MINE FOREMAN 1. Original and photocopies of Transcript ‘of Records/Diploma 2, Original and photocopy of Birth Certificate (NSO) 3. Original NBI Clearance 4. Ceifcate of Experience (PRC Form 104) 5. Certificate of Employment (atleast 5 yrs.) 4. Original and photocopy of Birth Certificate (NSO) 2. Original and photocopy of Mariage Certificate NSO (for married female) 3. Original and photocopy of Transcript of Records Orginal and photocopy of College diploma/High School diploma Duly notarized Service Record Duly notarized Certificate of Employment Certificate of Experience (PRC Form 104) NBI Clearance CHEMIST 1. Original and photocopy of Birth Cerificate (NSO) 2. Original and photocopy of Marriage Certificate NSO (for married female) 3. Original and photocopy of Transcript of Records 4, NBI Clearance 5. Original and photocopy Doctoral eeealnac eal Copy of Thesis. DETAILMAN 4 Orginal and photocopy of Transerint of Records/Diploma 2, Orginal and photocopy of Marriage Certicate NSO (For married female) 3. Geriicate of Employment (PRC Form 102.30) 1. Original and photocopy of ith Certificate (NSO) 2. Original and photocopy of Marriage Cerificate NSO (for married female) 3. Original and photocopy of Transcript of Records 4. Original and photocopy of College Diploma: 5. Duly notarized certificate of employment 6. Certificate of Experience (PRC Form 104) Duly notarized Service Record (for ‘government employees) 8, NBI Clearance 8, Cerificate of Registration and Professional ID as Architect 10.Copy of plan of interior design of building andior sample photos of ‘works 11 Affidauit of Interior Designer/Architect Cutoff date: 1998 LANDSCAPE ARCHITECT 1. Original ng pnotocopy of Birth Cerificate (NSO) 2. Original and photocopy of Marriage Contract in NSO (for marti fernale) 3, Orginal and photocopy of Transcript of Records 4, Certication under oath stating that the pplicant has worked and performed ‘8 a Landscape Architect for at least ten (10) years before the effectivity of RA. No. 9053 (dated March 30, 2001) 5. Ifthe applicant has practiced Landscape Architecture, at least one (1) copy ofa plan of a landscape architectural project for every year of Practice for ten (10) years before the ‘effectivity of RA No. 8053 oF a copy of atleast one (1) contract of Landscape ‘Architectural services entered into by ‘the applicant with a cent for every year of practice for ten (10) years before the effectivity of RA No. 8053 6. Original and photocopy of the Cortificate of Registration and Professional IO card as architect or ‘environmental planner 7. Certificate of Experience (PRC Form 104) PROFESSIONAL ELECTRICAL EN ENGINEER 1, Original and photocopy of Transcript of Records 2. Original and photocopy of Birth Gertficate (NSO) 3, Original and photocopy of Marriage Cerificate NSO (for married female) 4, NBI Clearance 5. Valid cerificate of registration and Professional ID as REE 6. Cortifoate of Experience (PRC Form 104) DICAL LAL BR (Sunkers with ratings of 70% or above) 1. Report of rating (optional) 2. Original NBI Clearance 3. Original and photocopy of Marriage Certificate NSO (for married female) METALLURGICAL PLANT. PLEASE SEE REQUIREMENTS FOR CERTIFIED MINE FOREMAN Br AL ENGINEER 1. Original and photocopy of Bith Cetifcate (NSO) 2. Original and photocopy of Marriage ertiicate NSO (for married female) 3, Original and photocopy of Transcript cof Records 4. Lists of designs undertaken withthe ‘supervision of a PME ‘5, Curriculum vitae 6. Two(2) titles of proposed reports each with a short wnte-up and table of conter 7. NBI Clearance {8 Current Professional ID as ME 9. Certificate of Competency 10. Affidavit of Applicant 11, Certificate of Experience (PRC Form 108) 12, Detelied Description of Machineries ‘and Equipment Handled TECHNOLOGIST 4. Orginal and photocopy of Birth Cerificate (NSO) 2. Original and photocopy of Mariage Contract in NSO (for married female) 3. Original and photocopies of Transcript of Records and Diploma Certificate of Experience (PRC Form Ni 4104) for Rad. Tech. only Ceaticate of Employment (for private ‘employees) — for Rad. Tech. only ‘Service Record (for gov't employees) - for Rad. Tech. only PART Cerificate of membership Original NBI Clearance ‘Authenticated copy of Report of Rating ‘fom DOH-RHS. Cut-off date 1992norror sate AA ee gear (eee ac 0 fom. 301200 REPRODUCTION NOTAUOWED (FROFESSIONTEORAD OF PERMANENT EXAMINATION AND REGISTRATION RECORD CARD late pind SOLD ate pers bapa) yourrecont inert passpoRr size — coored peur wih | cel ‘compete name tog Ina white bacground LD impostor WiLL BE |i ‘PROSECUTED emai et a 3 a esos fein are tue and covet st Sm fly aware that ny fase Invomason rencers mo abe | pasts] aa FBrerminal prosecutor =a Sana) le : : “|| crea nant) ‘Subsenbed and sworn to before me tha day of 20 at_____ffent ‘oplcant exhib to me nis Communty Tax Cerieate No, mr on (fight Tumbman PAC Adminstring OFfcar