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BOARD DATE OF EXAMINAI|ON
OF
SCHAAL GRADUATED FROM LOCATION OAfE OF GRADUAT|ON

REVIEW CENfER ATTENDED

WPE OF EXAMINATIAN PUCE OF EXAMINA|ION


COMPLETE THEORY ONLY
LAST
REMOVAL PRACTICAL ONLY EXAMIN ATION
TAKEN
lN CASE AF REMOVAL EXAMINATION, WR|TE THEORETICAL SUNECT(S) TO BE fAKEN BELOW:

1 3

2 4

PRACTICAL €X€RCISEIS) fO BE TAKEN

1 2

PERMANENT MAILING ADDRESS SIGNATURE OVER PRINTED NAI\IE

ln your usual handwritinq. copy the following paragraphs on the space provided hereunder.

ATTESTATION
ON
NON-DISCLOSURE DECLARATION

I declare upon my oath that I will not take from the examination room any examination questions which were used in the
licensure examination in which I am an examinee, or copy, reproduce and/or divulge or make know the nature oL content of
any examination question or answer to any individual or entity and I will report to the BOARD OF/FOR
oT the PROFESSIONAL REGULATION
COMMISSION (PRC) anybody who takes or brings out said examination questions from the examination room or copy or
reproduce the same.

I understand that failure on my part to comply with the above undertakings may result in the invalidation of my grades,
disqualification from future examination and/or may be subjected to criminal prosecution.

Signature of Examinee Administering Officer/Chairman of


(AfRant) Member of the Board

Date

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