PRC App Form No.

004

THIS FORM IS
Republic of the Philippines (Rev. Sept 2007)

NOT FOR Professional Regulation Commission

SALE
Lucena City PASTE HERE
PASSPORT SIZE PHOTO
with COMPLETE Name
Tag in plain white

__________________
APPLICATION FOR background
(taken within 3 months)
NAME OF BOARD REGISTRATION WITHOUT Scanned/Photocopied

EXAMINATION picture not acceptable

PERSONAL DATA
LAST NAME FIRST NAME MIDDLE NAME

GENDER CITIZENSHIP CIVIL STATUS DATE OF BIRTH

(mm/dd/yyyy)
SINGLE MARRIED
MALE FEMALE
WIDOWED SEPARATED
COMPLETE MAILING ADDRESS (House No. Street, Town/City, Province) ZIP CODE

PLACE OF BIRTH (Town/City, Province) TELEPHONE / CELULLAR PHONE NO.

SPOUSE NAME
CITIZENSHIP FATHER’S NAME
CITIZENSHIP MOTHER’S NAME
CITIZENSHIP

Have you ever been convicted in a final judgment by any court, military tribunal or administrative body?
YES NO (If yes, attach a copy of decision)

EDUCATIONAL DATA
COURSE/DEGREE
FROM TO
NAME OF SCHOOL LOCATION Completed (mm/dd/yyyy) (mm/dd/yyyy)

Vocational
College
Graduate/Post
Graduate

PREVIOUS LICENSURE EXAMINATION(S) TAKEN

VERIFIED BY PRC ID
NAME OF EXAMINATION DATE TAKEN
Record Section Registration Division YEAR EXPIRED

EMPLOYMENT RECORD
SPECIFIC FROM TO
OFFICE POSITION HELD
WORK/FUNCTION (mm/dd/yyyy) (mm/dd/yyyy)

ACTION TAKEN ACTION TAKEN BY THE BOARD

Remarks: _____________________
_______________________________
_______________________________
Processed by: ________________
Date:_________________________
ACTION TAKEN BY CASHIER
CHAIRMAN____________________
MEMBER ____________________
MEMBER ____________________
MEMBER ____________________
MEMBER ____________________
I HEREBY CERTIFY that the information and/or statements
in this application including the exhibits submitted in support thereof
are all true and correct of my own knowledge, and that I am fully
aware that any false information or statement in this application or in
its attachments shall render me liable for criminal prosecution and /
or administrative sanction.
________________________________________
Signature of Applicant

Amount: _____________________ Date: _________________________ RIGHT THUMBMARK ________________________________________

O.R. No.: _____________________ Issued by: ____________________ Date Accomplished

Subscribed and sworn to before me this ______________ day of __________________ 20_________

at_________________________________. Affiant applicant exhibited me his/her Community Tax Certificate No.
Metered
____________________issued at____________________________on___________________________
Documentary
Stamp
_________________________________
PRC Administering Officer

O.R.
K No.______________________
Amount Paid:_________________
REGISTRATION WITHOUT EXAMINATION
Date Paid:____________________ FOLLOW-UP SLIP
NAME:_____________________________________________________
PROFESSION:______________________________
DATE OF FILING:___________________________________________
Please verify approval of your application and resolution number at the Office of the Office of the Assistant Secretary at
(02) 735-1533 after three (3) months.
________________________________
Application Processor
 STEPS IN FILING APPLICATION FOR REGISTRATION WITHOUT EXAMINATION

1. Fill-out application form together with required documents for pre-evaluation to the Office of the Assistant Secretary
(3rd Floor, Main Bldg.) at the PRC Central Office and Regional Offices processing counters.
2. Go to the cashier for payment of fees. (Ground Floor, Main Bldg.)
3. Go to the Customer Service Center for metered documentary stamp and notarization. (Ground Floor, Annex Bldg.)
4. Submit duly accomplish application form to the Office of the Asst. Secretary.
5. After three (3) months, verify status of application at Tel. No. (02) 735-1533.

DOCUMENTS REQUIRED

PROFESSIONAL ELECTRONICS ENGINEER 4. If employed in the Government, original and

certified copy of service record, duly notarized.
1. Valid PRC ID as Electronics Engineer or Certificate If employed in private sector, a certificate under
as Electronics Engineer. oath issued by the authorized official/officer of
2. Valid IECEP ID or Certificate of Membership in the firm, company, association or corporation
good standing from IECEP engaged in the agriculture industry showing that
3. Certified experience record of active self-practice the applicant has served for at least five (5) years
and/or employment either in government service in a position which requires baccalaureate degree
or in private sector, in the format to be prescribed in Agriculture. (with detailed job description)
by the Board, indicating the inclusive dates, 5. Certification under oath of the authorized
companies worked for, description of specific official/officer of a private school,
responsibilities, relevant accomplishments and college/university showing that the applicant has
name, position of immediate supervisor for a served for at least 5 years before December 1997
period of at least seven (7) years (inclusive as faculty member/instructor and has taught
and/or aggregate), at least two (2) years of which subjects in Agriculture.
are in responsible charge of significant 6. Original and updated NBI Clearance (Private
engineering work, from the date applicant took Employee).
his/her oath as and Electronics and 7. Original and updated Ombudsman Clearance and
Communications Engineers or Electronics NBI Clearance (government employees).
Engineer. 8. 3 Certification of Good Moral Character (barangay
4. Three (3) certification signed by three (3) PECE captain, church, school or employer/dean).
attesting that the experience record submitted by
the applicant is factual (not needed for those who
have been registered and licensed as ECE under FISHERIES TECHNOLOGIST
R.A. 5734, for at least seven (7) years.
5. Original NBI Clearance (Private Sector) 1. Original and photocopy of Birth Certificate (NSO)
6. Original Ombudsman Clearance (for those in issued by NSO on Security Paper.
government service) 2. Original and photocopy of Marriage Contract
issued by NSO on Security Paper (for married
female).
ELECTRONICS TECHNICIAN 3. Original and photocopy of Transcript of Records
with Special Order (B), for graduates in private
1. Original and photocopy of NSO Birth Certificate schools. If doctorate degree is obtained abroad, a
2. Original and photocopy of NSO Marriage certification stating that the college/university
Certificate (for married female) has been recognized or authorized to operate.
3. Copy of Transcript of Records (Original to be (BS, MS, Ph. D.) & Diploma.
presented) 4. Certified Copy of report of rating issued by the
4. Copy of College Diploma Civil Service Commission showing that the
5. Duly notarized service record (for those in applicant has passed a civil service examination
government service) in Fisheries or the Career Service Professional
6. Duly notarized certificate of employment (Private examination.
Sector) 5. If employed in the Government, original and
7. Certificate of experience (PRC Form 104) certified copy of service record, duly notarized.
8. Original NBI Clearance (Private Sector) If employed in private sector, a certificate under
9. Original Ombudsman Clearance (for those in oath issued by the authorized official/officer of
government service) the firm, company, association or corporation
10. Proof of Membership with IECEP (valid IECEP ID) engaged in the agriculture industry showing that
11. Individual Certification from at least three (3) the applicant has served for at least five (5) years
registered PECE’s in a position which requires baccalaureate degree
in Agriculture or the Career Service Professional
eligibility; or (with detailed job description)
AGRICULTURIST 6. Certification under oath of the authorized
official/officer of a private school,
1. Original and photocopy of Birth Certificate issued college/university showing that the applicant has
by NSO on Security Paper. served for at least 5 years as faculty
2. Original and photocopy of Marriage Contract member/instructor and has taught subjects in
issued by NSO on Security Paper (for married Agriculture.
female). 7. Original and updated NBI Clearance (Private
3. Original and photocopy of Transcript of Records Employee).
with Special Order (B), for graduates in private 8. Original and updated Ombudsman Clearance and
schools. If doctorate degree is obtained abroad, a NBI Clearance (government employees).
certification stating that the college/university 9. Three Certification of Good Moral Character
has been recognized or authorized to operate. (barangay, church, school or employer/dean).
(BS, MS, Ph. D.) & Diploma.