Professional Documents
Culture Documents
Application Form 2011 (Various) - Web
Application Form 2011 (Various) - Web
001 WEB
(Revised September 2010)
REPRODUCTION
IS ALLOWED
Manila
PRC Central Office : APPLICATION DIVISION P. Paredes St., Sampaloc 1008 Manila, Philippines
Website : www.prc.gov.ph Tel. No.: (63-2) - 314-00-27
APPLICATION FORM
First Timer
Repeater
Conditioned
Absent
Name of Examination
Date of Examination
Place of Examination
Date (mm/dd/yy)
Scanned/Photocopied
picture not accepted
NOTICE : This application must be filled out in INK and in the applicants handwriting. All supporting documents shall become part of
the records of the Commiss ion. All applic ations must be f iled PERSONALLY by the applicant.
GIVEN NAME/S
SURNAME
Maiden Surname (for married female only)
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
Gender
Male
Civil Status
Single
Citizenship
Female
Filipino
(Town/City, Prov)
E-mail Address
Others ________________
RURBAN Code (Town/City, Prov)
RURBAN Code
Zip Code
Widow/er
Fathers Name & Citizenship
HAVE YOU EVER BEEN CHARGED AND CONVICTED BY FINAL JUDGEMENT BY ANY COURT OF JUSTICE/MILITARY TRIBUNAL OR
ADMINISTRATIVE BODY?
No
Yes
(If yes, attach hereto a copy of the decision)
Address/Location of School
Name of School
Degree/Course Obtained
Date Graduated
Address/Location of School
Name of School
(mm/dd/yy)
PRC SCHOOL
Code
PART III - PREVIOUS PRC LICENSURE EXAMINATION/S TAKEN (Last Three Exams)
Place of
Examination
Name of Examination
Self-Review
Review School/Center
STATUS CODES (refer at the back)
Date Taken
(mm/yy)
Rating
School-Based Review
NOTICE OF ADMISSION
(NOA)
REMARKS
PROCESSOR
RIGHT THUMBMARK
Signature of Applicant
Date Accomplished
Subscribed and sworn to before me this __________ day of
_____________ 20_____
11 at ______________. Affiant applicant exhibited
to me his/her Community Tax Certificate No.
Date
LEGAL OFFICER
ACTION TAKEN BY THE BOARD
APPROVED
DISAPPROVED
Stamp
AMOUNT PAID
CASHIER
PRC ADMINISTERING OFFICER
CONDITIONAL
REMARKS
Verified by
Exam No
Date
Date
IMPORTANT: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL MEAN NON INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF EXAMINATION FEES.
PLEASE READ THE REQUIREMENTS, STEPS and OTHER REMINDERS at the BACK
CHECKLIST OF REQUIREMENTS
Four (4) pcs Passport Size (1 1/2 x 1 1/2) colored pictures with full name tag
Community Tax Certificate (cedula)
Any valid IDENTIFICATION CARD
Affidavit of Competency (CPM)
Certificate of Registration/PRC License (Nurse-Midwife, Ocular Pharm)
*Certification of Good Moral Character - must come from any and/or all of the following :
Barangay, Church, School, and Employer
IMPORTANT
1. The Application Number and Room Assignment will be posted at www.prcbaguio.blogspot.com. Write your application
number on your Notice of Admission (NOA).
2. Keep and bring your Notice of Admission with Official Receipt.
3. Bring pencils (No. 1 or 2), ballpen (with black ink only), one piece (1) big brown envelope, one long transparent
plastic envelope.
4. Report to your school assignment before 6:30 a. m. on examination days. Late examinees will not be admitted.
This will mean forfeiture of examination fee.
5. DO NOT BRING HOME THIS APPLICATION FORM. This Form MUST BE ACCOMPLISHED AND SUBMITTED to the
Application Division for inclusion in the List of Examinees.
O-LIC/APPLIC