REFERENCE NO: CESHCTDERFHY | OR: E2023-10-06373495 | Amount: PHP 150.

00
Oct 11, 2023 (08:00 AM TO 09:00 AM) - Cotabato City - BARMM
NOTE: This appointment date might be different to the date of claiming of the requested authenticated documents
Professional Regulation Commission
ACTION SHEET FOR AUTHENTICATION

DATE FILED: Oct 10, 2023 Please underline: MALE/FEMALE

_______
NAME: ALI, PRINCESS KURNAISH SALIK
_____________________________________________________________________________________________
Last Name First Name Middle Name Married Name
PROFESSION: MIDWIFE REGISTRATION NO.: 0150468 REGISTRATION DATE: 11/25/2009
(For Professional Teacher, please tick [ ] Elementary [ ] Secondary)

VALIDITY DATE OF PROFESSIONAL IDENTIFICATION CARD (PIC): 07/07/2024 TEL./CP NO.: 09663301025

PLEASE CHECK BOX FOR TYPE OF DOCUMENT TO BE AUTHENTICATED:

CERTIFICATE OF REGISTRATION (COR) NO. OF COPIES PURPOSE:
CERTIFICATION OF BOARD RATING NO. OF COPIES LOCAL
CERTIFICATION OF GOOD STANDING NO. OF COPIES ABROAD
CERTIFICATION OF PASSING NO. OF COPIES LEGAL
X PROFESSIONAL IDENTIFICATION CARD NO. OF COPIES 2 STATEBOARD
REPORT OF RATINGS NO. OF COPIES OTHERS
OTHERS NO. OF COPIES

FOR PRC PROCESSING

150.00
Amount: ____________________________ Processed by: Prepared by:
_

E2023-10-06373495
O. R. No.: ___________________________
10/10/2023 ___________________________________ ____________________________________
Date: ___________________________
Signature over printed name Signature over printed name
LBP
Issued by: ___________________________
- Date: ______________________________ Date: ________________________________
Date due: __________________________

NOTE: AUTHENTICATION REQUIRES A VALID PROFESSIONAL IDENTIFICATION CARD.

AUTHENTICATION CLAIM SLIP

PLEASE FILL OUT THIS CLAIM SLIP

NAME: ALI, PRINCESS KURNAISH SALIK
_____________________________________ PROFESSION: MIDWIFE
___________________________
0150468
REGISTRATION NO.: _____________________________________ 11/25/2009
REGISTRATION DATE: ___________________________
DATE FILED: Oct 10, 2023
_____________________________________ -
DATE DUE: _____________________________________

PLEASE PRESENT THIS SLIP TO CLAIM DOCUMENTS AT ______________ ON ______________________. PRC REGISTERED
REPRESENTATIVE SHOULD PRESENT ANY VALID GOVERNMENT-ISSUED ID AND AUTHORIZATION LETTER; IF NOT REGISTERED
PROFESSIONAL, PRESENT SPECIAL POWER OF ATTORNEY(SPA)AND ANY VALID GOVERNMENT-ISSUED ID.

REGISTRATION OFFICER

IMPORTANT NOTES:

1. PLEASE ENSURE THAT YOU BRING THE ORIGINAL DOCUMENT YOU

WISH TO HAVE AUTHENTICATED.
2. ADDITIONALLY, PLEASE REMEMBER TO BRING THE CORRESPONDING
NUMBER OF PHOTOCOPIES OF THE SAME DOCUMENT THAT REQUIRE
AUTHENTICATION.

PRD-07
Rev. 00
October 16, 2020
Page 1 of 2