Professional Regulation Commission

This document is an application for renewal of a Professional Identification Card (PIC) in the Philippines. It provides details of the applicant such as name, date of birth, address, citizenship, school attended and date of graduation. It also lists the applicant's profession, license number, registration and expiration dates. The applicant declares that the information provided is true and correct, and acknowledges consent to the collection and processing of personal data. It notes the process and requirements for representatives applying for PIC renewal on behalf of professionals.

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Professional Regulation Commission

Uploaded by

Clark Jayden Jacob

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TIME RECEIVED:

TIME RELEASED:

Professional Regulation Commission

APPLICATION FOR PROFESSIONAL IDENTIFICATION CARD (PIC)

NOT FOR SALE (REPRODUCTION IS ALLOWED)

APPOINTMENT DATE: June 22, 2023 (10:00 AM TO 11:00 AM) - Robinsons Place Santiago
REFERENCE NO: REW72AC6BV8I | OR: E2023-06-05292366 | Amount: PHP 450.00
NAME: ECLAR, ELOISA JOY PATLI

CITIZENSHIP: FILIPINO BIRTHDATE: April 24, 1983

PERMANENT MAILING ADDRESS: 0 ALFONSO LISTA, IFUGAO(FORMERLY POTIA)

TEL. NO. / CP NO.: 09056933889 EMAIL ADDRESS: [email protected]
SCHOOL GRADUATED: ISABELA STATE UNIVERSITY-ECHAGUE DATE GRADUATED: March 23, 2003
REGISTRATION DATE: November 27, 2003 EXPIRATION DATE: April 24, 2026
PROFESSION: PROFESSIONAL TEACHER LICENSE NO.: 0824705

DECLARATION AND ATTESTATION

I am aware and I give my consent to the collection of the data required by this application form and
the taking of my photograph, and if applicable, the taking of my fingerprints.

I further attest that all particulars and supporting documents provided by me are correct and
complete. I am aware that any false statement or fraudulent document will lead to the rejection of my
application or to the cancellation of my PIC already issued, and may also render me liable under applicable
administrative and criminal laws.

SIGNATURE OF LICENSEE

UNDERTAKING

(To be filled up by professionals, except for Real Estate Practitioners, who failed to comply with the
required CPD Credit Units for the renewal of Professional Identification Card)

For this compliance period, I am submitting CPD units of the total required CPD Credit units. I
hereby undertake to submit the balance of CPD credit units in addition to the required CPD units (or a
total of units) for the next renewal of my PIC. I understand that in the event I fail to comply, my PIC will
not be renewed.

SIGNATURE OF LICENSEE

NOTE:
1) ALL REAL ESTATE PRACTITIONERS CANNOT AVAIL THE UNDERTAKING AND HAVE TO
PROVIDE PROOF OF COMPLIANCE WITH CPD PRIOR TO RENEWAL OF PIC PURSUANT TO
SECTION 17, ARTICLE III OF REPUBLIC ACT NO. 9646 OR THE REAL ESTATE SERVICE ACT
OF THE PHILIPPINES AND BOARD RESOLUTION NO. 49, S. 2015.
2) REPRESENTATIVE OF THE PROFESSIONAL APPLYING FOR ISSUANCE OF PROFESSIONAL
IDENTIFICATION CARD (PIC) MUST SUBMIT:
a) THE PRESCRIBED AUTHORIZATION LETTER AND PHOTOCOPY OF PROFESSIONAL
IDENTIFICATION CARD (PIC) OF THE REPRESENTATIVE AND EXPIRED PIC OF THE
PRFESSIONAL; OR
b) SPECIAL POWER OF ATTORNEY (SPA) AND PHOTOCOPY OF ANY VALID GOVERNMENT
ISSUED IDENTIFICATION CARD (ID) OF THE REPRESENTATIVE AND THE PROFESSIONAL
3) STRICTLY FOLLOW THE APPOINTMENT DATE ON RENEWAL OF PROFESSIONAL
IDENTIFICATION CARD (PIC).

REG-03
Rev. 02
September 15, 2017
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