Professional Regulation Commission

REQUEST FOR PERFORMANCE OF SCHOOL IN VARIOUS LICENSURE EXAMINATIONS

THIS FORM IS NOT FOR SALE

IMPORTANT: PLEASE READ GENERAL INSTRUCTIONS BEFORE FILLING UP THE FORM

1. PRINT letters in the spaces provided.

2. A valid ID is required for the requesting party and authorized representative,if applicable
3. Indicate below the name of the representative who will claim the documents.
4. Provide correct information and do not leave any entries blank

GENERAL INFORMATION
Date OCTOBER 27, 2022
School Name (no abbreviation please) CAPIZ STATE UNIVERSITY
Street BAILAN
Municipality PONTEVEDRA
Province/City CAPIZ
Region 6
Postal or Zip Code 5802
School Telephone (include Area Code) (036) 6340-144
School Fax No. (include Area Code) (036) 6340-144
School E-mail Address pontevedra@capsu.edu.ph
Mobile Number N/A

Request Details: ( Please use additional page/s if necessary)

DATE OF EXAMINATION/S REQUESTED DOCUMENTS
NAME OF LICENSURE EXAMINATION/S Certification of School Performance with List of Examinees
(Month and Year) the National Passing Rate with Ratings
LICENSURE EXAMINATION FOR TEACHERS - ELEMENTARY
1. LEVEL MARCH 2017 1 0
LICENSURE EXAMINATION FOR TEACHERS - ELEMENTARY
2. LEVEL SEPTEMBER 2017 1 0
LICENSURE EXAMINATION FOR TEACHERS - ELEMENTARY
3. LEVEL MARCH 2018 1 0
LICENSURE EXAMINATION FOR TEACHERS - ELEMENTARY
4. LEVEL SEPTEMBER 2018 1 0
LICENSURE EXAMINATION FOR TEACHERS - ELEMENTARY
5. LEVEL MARCH 2019 1 0
CONTINUED ON ATTACHED SHEET
This is to CERTIFY that the undersigned requesting party is duly authorized by the school, college or university
represented, and is aware that the Performance of Schools and/or Listing of Examinees is/are intended for the
use of the said institution for analysis, interpretation and evaluation purposes pursuant to PRC Resolution No.
2003 – 143,S.2003.

The undersigned further certifies that all information herein stated are true and correct.

Requesting Party:

FE MAE L. LABORTE AUTHORIZATION (if applicable)

Signature over Printed Name
I hereby authorize the bearer, Mr./Ms. ________________
FE MAE L. LABORTE
QUALITY ASSURANCE CHAIR 2006-20701-04
_____________________with ID No. _____________,
Designation duly issued by the institution to transact business in PRC in
behalf of our school.
OCTOBER 27, 2022
Date Accomplished HONEY LEE E. CASA Campus Administrator
Signature over Printed Name

ESD - 08
OCTOBER 27, 2022 Rev.00
Date Accomplished February 29, 2016
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