Professional Regulation Commission

PETITION FOR UPDATING OF PROFESSIONAL DATA/RECORD

DATE FILED: __________________

MANUEL VANESSA JOY QUINONES
NAME: ___________________________________________________________________________
Last Name First Name Middle Name Suffix Colored Picture with
CORPUZ VANESSA JOY MANUEL
MARRIED NAME: __________________________________________________________________ name tag in plain
(IF APPLICABLE) Last Name First Name Middle Name Suffix white background
MEDICAL TECHNOLOGIST
PROFESSION: ____________________________________________________________________ taken within last six
(6) months
0075722
REGISTRATION NO: _________________________ SEP. 1, 2016
REGISTRATION DATE: __________________
06-15-1995
DATE OF BIRTH: ____________________________ PLACE OF BIRTH: KABACAN, NORTH COTABATO
______________________ (Photo as required in
PERMANENT MAILING ADDRESS: ____________________________________________________
B3 L27 SUSANA HOMES SUBD. BRGY. BALIOK DAVAO CITY online.prc.gov.ph)
EMAIL ADDRESS: _____________________________
vanessamanuelrmt1995@gmail.com CONTACT NO.: _______________________
09486809996
MARRIED TO: ________________________________ FEBRUARY 28, 2024
CORPUZ, JHON CHRISTOPER DOLIGOSA DATE OF MARRIAGE: __________________

NAME TO APPEAR IN THE RECORDS OF THE COMMISSION AND PROFESSIONAL IDENTIFICATION CARD
PERSONAL DETAILS FROM TO
FIRST NAME VANESSA JOY VANESSA JOY
MIDDLE NAME QUINONES MANUEL
LAST NAME MANUEL CORPUZ
DATE OF BIRTH 06-15-1995 06-15-1995

THE UPDATING OF DATA IN THE RECORDS OF THE COMMISSION PARTICULARLY REFERS TO THE:
TYPE OF REQUEST FROM TO
CORRECTION OF GIVEN NAME/MIDDLE
NAME/SURNAME/SUFFIX/SEX
CORRECTION OF DATE OF BIRTH

REVERSION TO THE USE OF MAIDEN NAME

(MARRIED TO SINGLE)
CHANGE OF LEGAL STATUS (MARRIED TO
SINGLE)
CHANGE OF MARRIED NAME DUE TO
REMARRIAGE
CHANGE OF STATUS WITHOUT CHANGE OF
REGISTERED NAME
CHANGE OF STATUS AND REGISTERED NAME
X DUE TO MARRIAGE MANUEL, VANESSA JOY QUINONES CORPUZ, VANESSA JOY MANUEL

BASIC REQUIREMENTS:
1. System-generated Petition Form 3. Photocopy of Valid PRC ID/e-PIC
2. Original PSA Copy of Certificate of Live Birth 4. Documentary Stamp Tax

ADDITIONAL REQUIREMENTS:
1. CORRECTION/CHANGE OF GIVEN NAME/MIDDLE 4. CHANGE OF MARRIED NAME DUE TO REMARRIAGE:
NAME/SURNAME/SUFFIX, DATE OF BIRTH, AND SEX: a. Original PSA Copy of Certificate of Marriage with annotation
a. Original PSA Copy of Certificate of Marriage (for on the decision of NULLITY or presumptive death
registered married name only) b. Original PSA copy of Certificate of Death (in case of death of
b. Affidavit of Discrepancy (true and correct name/date of spouse)
birth) c. Original PSA copy of Certificate of Marriage (Subsequent
Marriage)
2. REVERSION TO THE USE OF MAIDEN NAME:
a. Original PSA Copy of Certificate of Marriage with 5. CHANGE OF STATUS WITHOUT CHANGE OF REGISTERED NAME
annotation on the decision of NULLITY or presumptive a. Original PSA copy of Certificate of Marriage
death b. Original PSA copy of Report of Marriage for marriages
b. Original PSA copy of Certificate of Death (in case of death contracted abroad
of spouse)
6. CHANGE OF STATUS AND REGISTERED NAME DUE TO MARRIAGE
3. CHANGE OF LEGAL STATUS (MARRIED TO SINGLE): X a. Original PSA copy of Certificate of Marriage
a. Original PSA Copy of Certificate of Marriage with b. Original PSA copy of Report of Marriage for marriages
annotation on the decision of NULLITY or presumptive contracted abroad
death
7. OTHERS, please specify:
b. Original PSA copy of Certificate of Death (in case of death
__________________________________________________________
of spouse)
__________________________________________________________

Note: Please make sure that you have the original copy of the pertinent documents for validation and verification. In case of non-readable entry/ies in the
Birth/Marriage Certificate, submit a copy of the document/s from Local Civil Registry (LCR)

I DO HEREBY CERTIFY that the information and statements in this petition including the documents/exhibits submitted in
support thereof are all true and correct of my own knowledge; and that I am fully aware that any false information or statement in this
petition or in any of the documents/exhibits shall hold me administratively/criminally and/or civilly liable.
FURTHER, I agree to the PRC Privacy Notice and hereby give my consent to the collection and processing of my personal
data in accordance thereto.
___________________________________
CORPUZ, VANESSA JOY MANUEL
Signature of Petitioner over Printed Name

SUBSCRIBED AND SWORN to before me this _______ day of __________ at __________________ affiant exhibiting to
me his/her ID__________________________issued/expires on _________________.
JUNE 15, 2024

Documentary
PRD-23
Stamp Tax Rev. 02
April 3, 2024
Page 1 of 2
 FOR PRC PROCESSING
REGULATION DIVISION
Registered Name: MANUEL, VANESSA JOY QUINONES
Profession: MEDICAL TECHNOLOGIST
Date of Birth: JUNE 15, 1995
Registration No: 0075722 Registration Date: SEPTEMBER 1, 2016
Verified and Processed by:

_______________________
VANESSA JOY Q. MANUEL
(Signature over Printed Name)

Note: Please make sure that you have the original copy of the pertinent documents for validation and further verification.

A. PROCEDURES:
1. Login using LERIS account (online.prc.gov.ph) to secure an appointment date, appointment place and select
payment option/channel.
2. Present the system generated petition form and other documentary requirements to the designated window.

B. REQUIREMENTS FOR REPRESENTATIVE

1. Non-registered professional must present any valid government-issued ID and Special Power of Attorney
(SPA) duly executed by the petitioner, and
2. Registered professional must present his/her valid Professional Identification Card (PIC) or e-PIC and
authorization letter duly signed by the concerned petitioner.

PRD-23
Rev. 02
April 3, 2024
Page 2 of 2