Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE

REPRODUCTION
IS ALLOWED

Application No.
Name of Examination _________________________________ Paste here your
recent
First Timer Elementary / Major _________________________________ passport size picture
Repeater with COMPLETE
Conditioned Date of Examination _________________________________ Name Tag
in plain white
Absent Place of Examination _________________________________ background
________________
Date(mm/dd/yy) Scanned/Photocopied
NOTICE: This application must be filled out in INK and in the applicant’s handwriting. All supporting shall become part of the picture not accepted
records of the Commission. All applications must be filed PERSONALLY by the applicant.

PART I-PERSONAL INFORMATION

SUR NAME GIVEN NAME/S MIDDLE NAME

Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)

Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address

Male Female Filipino Others______

Civil Status Date of Birth(mm/dd/yy) Place of Birth (City/Town,Prov) RURBAN

Single Married Widow/er Code(Town/City,Prov)

Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship

HAVE YOU EVER BEEN CHARGED AND CONVICTED BY FINAL JUDGEMENT BY ANY COURT OF JUSTICE/MILITARY TRIBUNAL OR
ADMINISTRATIVE BODY? 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

Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code

Other Higher Educational Attainment Name of School Address/Location of School Date Graduated PRC SCHOOL
(mm/dd/yy) CODE

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.

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

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
________________________issued at _______________
REMARKS ______________________________________________
on _____________.
______________________________________________________________________________

CHAIRMAN/ MEMBER ______________________ Date __________

_______________________________
PRC ADMINISTERING OFFICER
Administration of Oath Is Free
(Office Order No. 2009-377 & 2009-379
both dated September 3, 2009)
____________________________________________________________
ACTION TAKEN BY THE CASHIER
AMOUNT PAID ____________ OFFICIAL RECEIPT NO. _____________
CASHIER _________________________________ Date __________
____________________________________________________________
ACTION TAKEN BY THE ISSUING OFFICER
REMARKS _______________________________________________
______________________________________________________________________________
ISSUING OFFICER ________________________ Date __________

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 FEES
APP-01
Rev. 00
February 25, 2015
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