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Applicationform PDF
Applicationform PDF
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City) Zip Code RURBAN Code (Town/City, Prov)
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)
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board 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.
Certificate of Registration/PRC License (Nurse-Midwife, Ocular Pharm) Police & Court Clearances (Criminologist)
Certificate of 1,000 Case Hours (Social Worker) Record of Deliveries Handled (Midwife)
Certificate of Experience (CPM, Env’tal Planner, Landscape Arch, Master Record of OR-DR Cases (Nurse)
Plumber) Refresher Course (CPA, Dentist, Med Tech
Cerificate of Special Pharmacology Course (Ocular Pharmacology) PT & OT, Physician, Pharm, Opto)
Certificate of Employment (CPM, Env’tal Planner, Landscape Arch, Master Summary of Related Learning Experience
Plumber) Others CHED Permit/ Recognition for New
Certificate of Internship/OJT (Physician, Pharm, PT & OT, Dental Tech & Schools and / or New Programs
Hygienist)
*Certification of Good Moral Character [Agri (2), Crim (3), Fishery Tech (1), for BLURRED NSO Birth Cert/Marriage
Forester (2), Lib.(2), Env’tal P. (1)] Certificate. it MUST BE SUPPORTED BY the
Certification of Mine and Mill Practice (Mining Engineer) LOCAL CIVIL REGISTRY Birth Certificate
Copy of Thesis - Title Page & Approval Sheet (Chemist) and Marriage Certificate.
*Certification of Good Moral Character - must come from any and/or all of the following :
Barangay, Church, School, and Employer
2. Bring pencils (No. 1 or 2), ballpen (with black ink only), one piece (1) big brown envelope, one long transparent
plastic envelope.
3. 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.
4. DO NOT BRING HOME THIS APPLICATION FORM. This Form MUST BE ACCOMPLISHED & SUBMITTED to the
Application Division in order for your name to be included in the List of Examinees.