DATE OF EXAMINATION

BOARD
OF
SCHOOL GRADUATED FROM LOCATION DATE OF GRADUATION

REVIEW CENTER ATTENDED LOCATION DATE OF BIRTH SEX

TYPE OF EXAMINATION PLACE OF EXAMINATION MOBILE NUMBER

COMPLETE THEORY ONLY

LAST MONTH YEAR
EXAMINATION
REMOVAL PRACTICAL ONLY TAKEN

IN CASE OF REMOVAL EXAMINATION, WRITE THEORETICAL SUBJECT(S) TO BE TAKEN BELOW

1 3

2 4
PRACTICAL EXERCISE(S) TO BE TAKEN

1 2

PERMANENT MAILING ADDRESS SIGNATURE OVER PRINTED NAME

In your usual handwriting, copy the following paragraphs on the space provided hereunder.

ATTESTATION
ON
NON-DISCLOSURE DECLARATION

I declare upon my oath that I will not take from the examination room any examination questions which were used in
the licensure examination in which I am an examinee, or copy, reproduce and/or divulge or make known the nature of
content of any examination question or answer to any individual or entity and I will report to the BOARD
OF/FOR_________________________________ or the PROFESSIONAL REGULATION COMMISSION (PRC)
anybody who takes or brings out said examination question from the examination room or copy or reproduce the same.

I understand that failure on my part to comply with the above undertakings may result in the invalidation of my
grades, disqualification from future examinations and/or may be subjected to criminal prosecution.

Signature of Examinee PRC Administering Officer/Chairman or

(Affiant) Member of the Board

Date: