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APPOINTMENT DATE: Dec 17, 2018 (PM) - Robinson?

s Galleria (Ortigas) | OR: 15085283 | AMOUNT: PHP 600

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)


Application No.
612943
First Timer
Name of Examination MASTER PLUMBER
_________________________________
X Repeater
Conditioned Date of Examination February 12 - 13, 2019
_________________________________
Absent
Place of Examination Manila
_________________________________
________________
12/11/2018
Date(mm/dd/yy)
NOTICE: All supporting documents shall become part of the records of the Commission. All applications must be filed
PERSONALLY by the applicant.

PART I-PERSONAL INFORMATION


SUR NAME GIVEN NAME/S MIDDLE NAME
GUMBOC ALEXANDER BERNARDO
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
MANGGAHAN ST., PUROK-II ZONE-8, CUPANG ANTIPOLO, RIZAL
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
X Male Female X Filipino Others______ 09097442699 alexg.daaa@gmail.com
Civil Status Date of Birth(mm/dd/yy) Place of Birth (City/Town,Prov) RURBAN Code(Town/City,Prov)
X Single Married Widow/er 06/13/1989 SANTA FE, ROMBLON 135915
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
LAMBERTO C. GUMBOC JR. / FILIPINO NORBERTA B. GUMBOC / FILIPINO
HAVE YOU EVER BEEN CHARGED AND CONVICTED BY FINAL JUDGEMENT BY ANY COURT OF JUSTICE/MILITARY TRIBUNAL OR
ADMINISTRATIVE BODY? X No Yes (If yes, attach hereto a copy of the decision)
PART II – EDUCATIONAL INFORMATION
Name of School Address/Location of School PRC School code
ROMBLON STATE UNIVERSITY-ODIONGAN (formerly ROMBLON STATE
ODIONGAN,
COLLEGE)
ROMBLON 0895
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BS IN CIVIL ENGINEERING 3044 04/03/2011 1900
Date Graduated PRC SCHOOL
Other Higher Educational Attainment Name of School Address/Location of School CODE
(mm/dd/yy)

PART III – PREVIOUS PRC LICENSURE EXAMINATION/S TAKEN (Last Three Exams)
Place of Date Taken Result of Examination (pls check)
Name of Examination Rating Exam No. Verified by
Examination (mm/yy) Passed Failed Cond.
MASTER PLUMBER - 07/2018 57.60 X
MASTER PLUMBER - 07/2017 47.40 X

Review School/Center: Self-Review School-Based Review Others (specify name) __________________________


STATUS CODES (refer at the back) 1.) Examination Type (EXcode) 2.) Number of Times Taken 2

I HEREBY CERTIFY that the information and/or ACTION TAKEN BY THE APPLICATION PROCESSOR
statements in this application including the supporting ISSUANCE of the FOLOWING FORMS
documents submitted in support thereof are all true and
correct to my own knowledge, and that I am fully aware that NOTICE OF ADMISSION PERMANENT EXAMINATION &
(NOA) REGISTRATION RECORD CARD (PERRC)
any false information or statement in this application or in its
attachments shall render me liable for criminal prosecution REMARKS ______________________________________________
and/or administrative sanction. ______________________________________________________________________________

PROCESSOR_____________________________ Date ___________


RIGHT THUMBMARK _______________________ ____________________________________________________________
Signature of Applicant ACTION TAKEN BY LEGAL OFFICER (if applicable)
_______________________ REMARKS ______________________________________________
Date Accomplished ______________________________________________________________________________

LEGAL OFFICER __________________________ Date ___________


Subscribed and sworn to before me this __________day of ____________________________________________________________
_________20____at__________. Affiant applicant exhibited ACTION TAKEN BY THE BOARD
to me his / her Community Tax Certificate No. APPROVED DISAPPROVED CONDITIONAL
03-050952170-7
________________________issued TAGUIG
at _______________
REMARKS ______________________________________________
on _____________.
06/05/2018 ______________________________________________________________________________
DOCUMENTARY STAMP

CHAIRMAN/ MEMBER ______________________ Date __________


____________________________________________________________
ACTION TAKEN BY THE CASHIER
_______________________________
PRC ADMINISTERING OFFICER AMOUNT PAID ____________
600 OFFICIAL RECEIPT NO. _____________
15085283
PRC
CASHIER _________________________________ 12/17/2018
Date __________
____________________________________________________________
ACTION TAKEN BY THE ISSUING OFFICER
Administration of Oath Is Free REMARKS _______________________________________________
(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 APP-01
NON-INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF EXAMINATION FEES Rev. 00
February 25, 2015
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