Republic of the Philippines

Department of Transportation
LAND TRANSPORTATION OFFICE
Photo of A
APPLICATION FOR REGISTRATION OF PHYSICIAN

CLINICAL INFORMATION
Clinic Name
Address
Medical Clinic Accreditation Number
PHYSICIAN INFORMATION
Last Name Sex Female Male
First Name Email Address
Middle Name Contact No.
Birth Date PRC No.
Month Day Year Specialization (if any)

Signature over Printed Name Date

Indorsed by:

Signature over Printed Name of Owner/Authorized Representative Date

To be filled out by LTO Authorized Personnel

Documents Submitted by Applicant:

Two pieces 2x2 photo with name tag within the last three months Clinic Code
from the date of application for registration;
Certified true copy of Certificate of Registration duly issued by Username
the Board of Medical Examiners;
Certificate of Membership and good standing from the Medical
Association of its component society;
Certificate of good standing from the Professional Regulation Registered by:
Commission;
Photocopy of the valid Professional Regulation Commission
license card (original copy presented during registration);
Copy of valid government issued identification card (other than LTO Authorized Personnel
PRC) with photo and signature (original copy presented during (Printed Name & Signature)
registration);
Current Professional Tax Receipt (PTR) number except for
government physician;
Taxpayer's Identification Number (TIN);
Digital Photograph and Biometric Scan of the Physician;
For government physicians, certified true copy of approved
appointment or Certificate of Employment issued by the agency;
For government physicians who desire to engage in private
practice, Authority to Engage in the Private Practice of Profession
approved by the Head of Agency where he/she is employed.

Approved by: Date:

LTO Authorized Signatory

(Printed Name & Signature)

Fingerprint Impression (must be taken immediately after registration)

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 Photo of Applicant

Male

Date

Date

Date:

ation)
Right Little Finger

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