APPOINTMENT DATE: Sep 18, 2019 (08:00 AM TO 09:00 AM) - PRC Iloilo

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)

REFERENCE NO: EXXCK4LZVLSF
Application No.
- OR: - | AMOUNT: PHP -

X First Timer
Repeater Name of Examination CRIMINOLOGIST
Conditioned Date of Examination November 29, 30 & Dec. 1, 2019
Absent
08/26/2019 Place of Examination Iloilo
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
ALIPONGGA GEORGE JR MAGTOLIS
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
SALAMANCA BARANGQY SAN MIGUE LA CARLOTA, NEGROS OCCIDENTAL
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
X Male Female X Filipino Others______ 09121041706 / 09121041706 georgealipongga@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 06/12/1997 LA CARLOTA, NEGROS OCCIDENTAL 064516

Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
GEORGE MAGTOLIS ALIPONGGA / FILIPINO LORNA MAGTOLIS ALIPONGGA / 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
LA CARLOTA CITY COMMUNITY COLLEGE LA CARLOTA CITY, NEGROS OCCIDENTAL 0294
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BS IN CRIMINOLOGY 9002 03/28/2019 3500
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 ACTION TAKEN BY THE APPLICATION PROCESSOR
statements in this application including the supporting ISSUANCE of the FOLOWING FORMS
documents submitted in support thereof are all true and
NOTICE OF ADMISSION PERMANENT EXAMINATION &
correct to my own knowledge, and that I am fully aware that (NOA) REGISTRATION RECORD CARD (PERRC)
any false information or statement in this application or in its
attachments shall render me liable for criminal prosecution REMARKS ______________________________________________
and/or administrative sanction. ______________________________________________________________________________

PROCESSOR_____________________________ Date ___________

RIGHT THUMBMARK _______________________ ____________________________________________________________
Signature of Applicant ACTION TAKEN BY LEGAL OFFICER (if applicable)
_______________________ REMARKS ______________________________________________
Date Accomplished ______________________________________________________________________________

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
issued at
REMARKS ______________________________________________
on . ______________________________________________________________________________
M
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P
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CHAIRMAN/ MEMBER ______________________ Date __________

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_______________________________
PRC ADMINISTERING OFFICER
Administration of Oath Is Free
(Office Order No. 2009-377 & 2009-379
both dated September 3, 2009)
____________________________________________________________
ACTION TAKEN BY THE CASHIER
AMOUNT PAID - OFFICIAL RECEIPT NO. -
CASHIER PRC - CASHIER Date -
____________________________________________________________
ACTION TAKEN BY THE ISSUING OFFICER
REMARKS _______________________________________________
______________________________________________________________________________
ISSUING OFFICER ________________________ Date __________

IMPORTANT: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL MEAN NON- APP-01
INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF EXAMINATION FEES Rev. 00
February 25, 2015
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