APPOINTMENT DATE: Jan 18, 2023 (09:00 AM TO 10:00 AM) - My Metro Town Mall

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)

REFERENCE NO: EX46Z0NXQD0Y
Application No.
OR: E2023-01-03687662 | AMOUNT: PHP 900.00
020772
FirstXTimer
Repeater Name of Examination MEDICAL TECHNOLOGIST
Conditioned
Date of Examination MARCH 8 - 9, 2023
Absent
01/17/2023 Place of Examination Manila
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
OBILLO AIRA ZALIVIA VALDEZ
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
LOT 42-43 PHASE 1 BLOCK 2 NHA BUROT TARLAC, TARLAC
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
Male X Female X Filipino Others 09171489215 airaobillo198@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 06/02/1999 TARLAC, TARLAC 036916
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
RIZALDO B. OBILLO / FILIPINO EVA V. OBILLO / 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
CENTRAL LUZON DOCTOR'S HOSPITAL EDUCATIONAL INSTITU TTIOANRLAC CITY, TARLAC 0898
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BS IN MEDICAL TECHNOLOGY 4017 08/12/2022 2110
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 0

I HEREBY CERTIFY that the information and/or

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

PROCESSOR Date
RIGHT THUMBMARK
Signature of Applicant
ACTION TAKEN BY LEGAL OFFICER (if applicable)
Date Accomplished REMARKS
_

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
4794-0630-7368-9532 issued at PSA OFFICE TARLAC
on 07/16/2022 . REMARKS
_
DOCUMENTARY STAMP

CHAIRMAN/ MEMBER Date

PRC
ACTION TAKEN BY THE CASHIER
AMOUNT PAID 900.00 OFFICIAL RECEIPT NOE. 2023-01-03687662
CASHIER Paymaya - _Gcash Payment _ Date 01/17/2023
Administration of Oath Is Free
(Office Order No. 2009-377 & 2009-379 ACTION TAKEN BY THE ISSUING OFFICER
both dated September 3, 2009)
REMARKS
_

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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