ANNEX D

REPUBLIC OF THE PHILIPPINES

Professional Regulation Commission
Regional Office XI

AUTHENTICATION OF RA 1080 ELIGIBILITY OF PRC REGISTERED PROFESSIONALS

To the applicant Please fill out this form completely and legibly in BLOCK letters using BLACK
or BLUE INK and submit to the Professional Regulation Commission Regional
Office XI, together with the documentary requirements for the
authentication of your RA 1080 eligibility as a PRC registered professional.

Only signed and valid Professional Identification Cards (PIC) shall be

authenticated; otherwise, please have your expired PICs renewed prior
authentication.
To the HRMO of the Please submit this form to the CSC together with the applicant’s
hiring agency authenticated PIC and other documentary requirements for the processing
and evaluation of applicant’s appointment.

AUTHENTICATION REQUEST FORM

____________________________________________
PART I. PORTION TO BE FILLED OUT BY THE APPLICANT

A] Personal Details

NAM
E
Last Name First Name Middle Name

MAIDEN NAME DATE OF BIRTH

PERMANENT ADDRESS

E-MAIL ADDRESS CONTACT NUMBER

PROFESSION REGISTRATION/LICENSE NUMBER

DATE OF REGISTRATION PRC ID EXPIRATION DATE

B] Prospective Employer’s Information

AGENCY HEAD: REYNALDO M. GUILLENA DESIGNATION: SCHOOLS DIVISION SUPERINTENDENT

NAME OF AGENCY: DEPED – DAVAO CITY

ADDRESS: ELPIDIO QUIRINO AVENUE, DAVAO CITY

E-MAIL ADDRESS: personnel.davaocity@deped.gov.ph CONTACT NUMBER: 225-5049

Signature Over Printed Name of Applicant Date :

REGDIV
REV. 01
APRL 05, 2019
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