Professional Regulation Commission ACTION SHEET FOR REGISTRATION . | Balle filed. nn NAME _- LICENSE NO. _____ DATE REGISTERED: LEVEL (for TEACHERS only) PROFESSION: _. é ene [7 oricmat cerTiFIcATION oo AUTHENTICATION NO. OF COPIES:___ CONTACT NO. Certificate of Good Standing ertifcate of Good Standing Others: _ [ — [] cenincate of Registration ———__ TOR PRE PROCESSING } Amount: ORNos Processed by: | Issued by: _ _______ Date due: 0: NOTE: CERTIFICATION REQUIRES A VALIO/CURRENT PROFESSIONAL IDENTIFICATION CARD. CERTIFICATION CLAIM SLIP. DATE FILED. ORIGINAL CERTIFICATION AUTHENTICATION NAME: .. _ Document Requesteo: Cast Name First Name Middie Name Martied Name PROFESSION . Official Receipt No corn Amount Paid Oates mmiyyyy Pigase present this slip to clalm documents at —) . INTATIVE WITH PROPER IDENTIFICATION SHOULD PRESENT AUTHORIZAT| a ee Ce 01 TON LETTER AND VALID IDENTIFICATION REGISTRATION OFFICER Luc-REG.o2 Rev. 00 2017 e102