REFERENCE NO: CEMS8ZV70QS7 | OR: E2024-01-07396750 | Amount: PHP 75.

00
Feb 08, 2024 (02:00 PM TO 3:00 PM) - Robinsons Sta. Rosa
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: Jan 29, 2024 Please underline: MALE/FEMALE

_______
NAME: ATIENZA, ROMA MAE CONSIGNA
_____________________________________________________________________________________________
Last Name First Name Middle Name Married Name
PROFESSION: PROFESSIONAL TEACHER REGISTRATION NO.: - REGISTRATION DATE: -
(For Professional Teacher, please tick [ ] Elementary [ ] Secondary)

VALIDITY DATE OF PROFESSIONAL IDENTIFICATION CARD (PIC): TEL./CP NO.: 09995726940

PLEASE CHECK BOX FOR TYPE OF DOCUMENT TO BE AUTHENTICATED:

CERTIFICATE OF REGISTRATION (COR) NO. OF COPIES PURPOSE:
CERTIFICATION OF BOARD RATING NO. OF COPIES LOCAL
CERTIFICATION OF GOOD STANDING NO. OF COPIES ABROAD
X CERTIFICATION OF PASSING NO. OF COPIES 1 LEGAL
PROFESSIONAL IDENTIFICATION CARD NO. OF COPIES STATEBOARD
REPORT OF RATINGS NO. OF COPIES OTHERS
OTHERS NO. OF COPIES

FOR PRC PROCESSING

75.00
Amount: ____________________________ Processed by: Prepared by:
_

E2024-01-07396750
O. R. No.: ___________________________
01/29/2024 ___________________________________ ____________________________________
Date: ___________________________
Signature over printed name Signature over printed name
PAYMAYA-GCASH
Issued by: ___________________________
- Date: ______________________________ Date: ________________________________
Date due: __________________________

NOTE: AUTHENTICATION REQUIRES A VALID PROFESSIONAL IDENTIFICATION CARD.

AUTHENTICATION CLAIM SLIP

PLEASE FILL OUT THIS CLAIM SLIP

NAME: ATIENZA, ROMA MAE CONSIGNA
_____________________________________ PROFESSION: PROFESSIONAL TEACHER
___________________________
-
REGISTRATION NO.: _____________________________________ -
REGISTRATION DATE: ___________________________
DATE FILED: Jan 29, 2024
_____________________________________ -
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

IMPORTANT NOTES:

1. PLEASE ENSURE THAT YOU BRING THE ORIGINAL DOCUMENT YOU

WISH TO HAVE AUTHENTICATED.
2. ADDITIONALLY, PLEASE REMEMBER TO BRING THE CORRESPONDING
NUMBER OF PHOTOCOPIES OF THE SAME DOCUMENT THAT REQUIRE
AUTHENTICATION.

PRD-07
Rev. 00
October 16, 2020
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