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    Application Form: Professional Regulation Commission

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    Jennifer Dela Cruz Fortu
    This document is an application form for the Professional Regulation Commission's Professional Teacher licensure exam. It contains personal information about the applicant such as name, address, educational background, and details of previous exams taken. The applicant is applying to retake the exam in September 2019 and is providing certification that the information in the application is true and accurate. The various sections of the application form are for processing by PRC personnel such as the application processor, legal officer, board, cashier, and issuing officer.

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    Application Form: Professional Regulation Commission

    Uploaded by

    Jennifer Dela Cruz Fortu
    70 views1 page
    This document is an application form for the Professional Regulation Commission's Professional Teacher licensure exam. It contains personal information about the applicant such as name, address, educational background, and details of previous exams taken. The applicant is applying to retake the exam in September 2019 and is providing certification that the information in the application is true and accurate. The various sections of the application form are for processing by PRC personnel such as the application processor, legal officer, board, cashier, and issuing officer.

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    This document is an application form for the Professional Regulation Commission's Professional Teacher licensure exam. It contains personal information about the applicant such as name, address, educational background, and details of previous exams taken. The applicant is applying to retake the exam in September 2019 and is providing certification that the information in the application is true and accurate. The various sections of the application form are for processing by PRC personnel such as the application processor, legal officer, board, cashier, and issuing officer.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    70 views1 page

    Application Form: Professional Regulation Commission

    Uploaded by

    Jennifer Dela Cruz Fortu
    This document is an application form for the Professional Regulation Commission's Professional Teacher licensure exam. It contains personal information about the applicant such as name, address, educational background, and details of previous exams taken. The applicant is applying to retake the exam in September 2019 and is providing certification that the information in the application is true and accurate. The various sections of the application form are for processing by PRC personnel such as the application processor, legal officer, board, cashier, and issuing officer.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    APPOINTMENT DATE: Jun 06, 2019 (AM) - PRC Lucena | OR: - | AMOUNT: PHP -

    Professional Regulation Commission

    APPLICATION FORM

    NOT FOR SALE (REPRODUCTION IS ALLOWED)


    REFERENCE NO:
    Application No.
    EX3H63X63VHD
    -
    First Timer PROFESSIONAL TEACHER
    Name of Examination Secondary(Social Studies)
    _________________________________
    X Repeater
    Conditioned Date of Examination September 29, 2019
    _________________________________
    Absent
    Place of Examination Romblon
    _________________________________
    ________________
    06/04/2019
    Date(mm/dd/yy)
    NOTICE: All supporting documents shall become part of the records of the Commission. All applications must be filed
    PERSONALLY by the applicant.

    PART I-PERSONAL INFORMATION


    SUR NAME GIVEN NAME/S MIDDLE NAME
    LLANDERAL MA CHRISTY MANZALAY
    Maiden Surname (for married female only)
    MANZALAY
    Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
    BARANGAY PANGULO, CALATRAVA, ROMBLON 5503 CALATRAVA, ROMBLON
    Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
    Male X Female X Filipino Others______ 09398523822 [email protected]
    Civil Status Date of Birth(mm/dd/yy) Place of Birth (City/Town,Prov) RURBAN Code(Town/City,Prov)
    Single X Married Widow/er 12/13/1983 MARILAO, BULACAN 031411
    Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
    RICHARD GONZALES LLANDERAL / FILIPINO ALEJANDRE FRONDA MANZALAY / FILIPINO DIODITA MADULA MALLORCA / FILIPINO
    HAVE YOU EVER BEEN CHARGED AND CONVICTED BY FINAL JUDGEMENT BY ANY COURT OF JUSTICE/MILITARY TRIBUNAL OR
    ADMINISTRATIVE BODY? X No Yes (If yes, attach hereto a copy of the decision)
    PART II – EDUCATIONAL INFORMATION
    Name of School Address/Location of School PRC School code
    ROMBLON STATE UNIVERSITY-CALATRAVA (formerly ROMBLON STATE
    CALATRAVA,
    COLLEGE)
    ROMBLON 2192
    Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
    BS IN INFORMATION TECHNOLOGY 9507 04/04/2006 4000
    Date Graduated PRC SCHOOL
    Other Higher Educational Attainment Name of School Address/Location of School CODE
    (mm/dd/yy)

    PART III – PREVIOUS PRC LICENSURE EXAMINATION/S TAKEN (Last Three Exams)
    Place of Date Taken Result of Examination (pls check)
    Name of Examination Rating Exam No. Verified by
    Examination (mm/yy) Passed Failed Cond.
    PROFESSIONAL TEACHER - 09/2018 60.80 X
    PROFESSIONAL TEACHER - 09/2015 58.00 X

    Review School/Center: Self-Review School-Based Review Others (specify name) __________________________


    STATUS CODES (refer at the back) 1.) Examination Type (EXcode) 2.) Number of Times Taken 2

    I HEREBY CERTIFY that the information and/or ACTION TAKEN BY THE APPLICATION PROCESSOR
    statements in this application including the supporting ISSUANCE of the FOLOWING FORMS
    documents submitted in support thereof are all true and
    correct to my own knowledge, and that I am fully aware that NOTICE OF ADMISSION PERMANENT EXAMINATION &
    (NOA) REGISTRATION RECORD CARD (PERRC)
    any false information or statement in this application or in its
    attachments shall render me liable for criminal prosecution REMARKS ______________________________________________
    and/or administrative sanction. ______________________________________________________________________________

    PROCESSOR_____________________________ Date ___________


    RIGHT THUMBMARK _______________________ ____________________________________________________________
    Signature of Applicant ACTION TAKEN BY LEGAL OFFICER (if applicable)
    _______________________ REMARKS ______________________________________________
    Date Accomplished ______________________________________________________________________________

    LEGAL OFFICER __________________________ Date ___________


    Subscribed and sworn to before me this __________day of ____________________________________________________________
    _________20____at__________. Affiant applicant exhibited ACTION TAKEN BY THE BOARD
    to me his / her Community Tax Certificate No. APPROVED DISAPPROVED CONDITIONAL
    0111-6898947-3
    ________________________issued SSS-NAGA CITY, CAMARINES SUR
    at _______________
    REMARKS ______________________________________________
    on _____________.
    04/03/2017 ______________________________________________________________________________
    DOCUMENTARY STAMP

    CHAIRMAN/ MEMBER ______________________ Date __________


    ____________________________________________________________
    ACTION TAKEN BY THE CASHIER
    _______________________________
    PRC ADMINISTERING OFFICER AMOUNT PAID ____________
    - OFFICIAL RECEIPT NO. _____________
    -
    PRC - CASHIER
    CASHIER _________________________________ -
    Date __________
    ____________________________________________________________
    ACTION TAKEN BY THE ISSUING OFFICER
    Administration of Oath Is Free REMARKS _______________________________________________
    (Office Order No. 2009-377 & 2009-379 ______________________________________________________________________________
    both dated September 3, 2009)
    ISSUING OFFICER ________________________ Date __________

    IMPORTANT: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL MEAN APP-01
    NON-INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF EXAMINATION FEES Rev. 00
    February 25, 2015
    Page 1 of 1

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