REFERENCE NO: CE5VCOS8B10J | OR: 114509912258 | Amount: PHP 375.

00
May 27, 2021 (02:00 PM TO 03:00 PM) - Robinsons Starmills
NOTE: This appointment date might be different to the date of claiming of the requested authenticated documents
Professional Regulation Commission
ACTION SHEET FOR AUTHENTICATION

DATE FILED: May 25, 2021 Please underline: MALE/FEMALE

_______
NAME: BUTARAN, RIZZA MAS
_____________________________________________________________________________________________
Last Name First Name Middle Name Married Name
PROFESSION: NURSE REGISTRATION NO.: - REGISTRATION DATE: -
(For Professional Teacher, please tick [ ] Elementary [ ] Secondary)

VALIDITY DATE OF PROFESSIONAL IDENTIFICATION CARD (PIC): TEL./CP NO.: 09662117940

PLEASE CHECK BOX FOR TYPE OF DOCUMENT TO BE AUTHENTICATED:

CERTIFICATE OF REGISTRATION (COR) NO. OF COPIES PURPOSE:
X CERTIFICATION OF BOARD RATING NO. OF COPIES 5 LOCAL
CERTIFICATION OF GOOD STANDING NO. OF COPIES ABROAD
CERTIFICATION OF PASSING NO. OF COPIES LEGAL
PROFESSIONAL IDENTIFICATION CARD NO. OF COPIES STATEBOARD
REPORT OF RATINGS NO. OF COPIES OTHERS
OTHERS NO. OF COPIES

FOR PRC PROCESSING

375.00
Amount: ____________________________ Processed by: Prepared by:
_

114509912258
O. R. No.: ___________________________
05/25/2021 ___________________________________ ____________________________________
Date: ___________________________
Signature over printed name Signature over printed name
PAYMAYA-WALLET
Issued by: ___________________________
- Date: ______________________________ Date: ________________________________
Date due: __________________________

NOTE: AUTHENTICATION REQUIRES A VALID PROFESSIONAL IDENTIFICATION CARD.

AUTHENTICATION CLAIM SLIP

PLEASE FILL OUT THIS CLAIM SLIP

NAME: BUTARAN, RIZZA MAS
_____________________________________ PROFESSION: NURSE
___________________________
-
REGISTRATION NO.: _____________________________________ -
REGISTRATION DATE: ___________________________
DATE FILED: May 25, 2021
_____________________________________ -
DATE DUE: _____________________________________

PLEASE PRESENT THIS SLIP TO CLAIM DOCUMENTS AT ______________ ON ______________________. PRC REGISTERED
REPRESENTATIVE SHOULD PRESENT ANY VALID GOVERNMENT-ISSUED ID AND AUTHORIZATION LETTER; IF NOT REGISTERED
PROFESSIONAL, PRESENT SPECIAL POWER OF ATTORNEY(SPA)AND ANY VALID GOVERNMENT-ISSUED ID.

REGISTRATION OFFICER

PLEASE SEE THE REQUIREMENTS AND PROCEDURES AT THE BACK OF THIS SHEET

PRD-07
Rev. 00
October 16, 2020
Page 1 of 2