APPOINTMENT DATE: Feb 03, 2020 (10:00 AM TO 11:00 AM) - Robinsons Place Ormoc Professional Regulation Commission APPLICATION FORM NOT FOR SALE (REPRODUCTION IS ALLOWED) REFERENCE NO: EXYA3ZYWA7O9 OR: 9460719 | AMOUNT: PHP 600 Application No. 000334 X First Timer Repeater Conditioned Absent 01/31/2020 ________________ Name of Examination REGISTERED MASTER ELECTRICIAN _________________________________ Date of Examination APRIL 16, 2020 _________________________________ Place of Examination Cebu _________________________________ 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 AYING EDWARD ROY Maiden Surname (for married female only) MIDDLE NAME CAPUYAN Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City) PUROK 5/PROPER 1/BARANGAY PUERTO BELLO MERIDA, LEYTE Gender Citizenship Contact numbers (Landline & Mobile) X Male X Filipino Female Others______ 09300468634 E-mail Address [email protected] Civil Status X Single RURBAN Code(Town/City,Prov) 083736 Married Date of Birth(mm/dd/yy) 09/14/1994 Widow/er Spouse’s name & Citizenship Place of Birth (City/Town,Prov) MERIDA, LEYTE Father’s Name & Citizenship ROGELIO S. AYING / FILIPINO Mother’s Name & Citizenship EDUVIGES C. AYING / 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 EASTERN VISAYAS STATE UNIV. (FOR. L.I.T.)-ORMOC CAMPUS ORMOC CITY, LEYTE 1755 Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code BS IN ELECTRICAL ENGINEERING 3047 01/27/2020 1150 PRC SCHOOL Date Graduated 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 Examination Name of Examination REGISTERED MASTER ELECTRICIAN - Date Taken (mm/yy) 09/2021 Rating Exam No. Verified by .00 Review School/Center: Self-Review School-Based Review STATUS CODES (refer at the back) 1.) Examination Type (EXcode) I HEREBY CERTIFY that the information and/or statements in this application including the supporting documents submitted in support thereof are all true and correct to my own knowledge, and that I am fully aware that any false information or statement in this application or in its attachments shall render me liable for criminal prosecution and/or administrative sanction. Result of Examination (pls check) Passed Failed Cond. Others (specify name) __________________________ 2.) Number of Times Taken 1 ACTION TAKEN BY THE APPLICATION PROCESSOR ISSUANCE of the FOLOWING FORMS NOTICE OF ADMISSION PERMANENT EXAMINATION & (NOA) REGISTRATION RECORD CARD (PERRC) REMARKS ______________________________________________ ______________________________________________________________________________ PROCESSOR_____________________________ Date ___________ RIGHT THUMBMARK _______________________ Signature of Applicant _______________________ Date Accomplished ____________________________________________________________ ACTION TAKEN BY LEGAL OFFICER (if applicable) REMARKS ______________________________________________ ______________________________________________________________________________ LEGAL OFFICER __________________________ Date ___________ DOCUMENTARY STAMP Subscribed and sworn to before me this __________day of _________20____at__________. Affiant applicant exhibited to me his / her Community Tax Certificate No. SCHOOL ID EVSU ________________________issued at _______________ 06/15/2016 on _____________. ____________________________________________________________ ACTION TAKEN BY THE BOARD APPROVED DISAPPROVED CONDITIONAL REMARKS ______________________________________________ ______________________________________________________________________________ CHAIRMAN/ MEMBER ______________________ Date __________ ____________________________________________________________ _______________________________ PRC ADMINISTERING OFFICER ACTION TAKEN BY THE CASHIER AMOUNT PAID ____________ OFFICIAL RECEIPT NO. _____________ 600 9460719 PRC - CASHIER 02/03/2020 CASHIER _________________________________ Date __________ ____________________________________________________________ Administration of Oath Is Free (Office Order No. 2009-377 & 2009-379 both dated September 3, 2009) ACTION TAKEN BY THE ISSUING OFFICER REMARKS _______________________________________________ ______________________________________________________________________________ ISSUING OFFICER ________________________ Date __________ IMPORTANT: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL MEAN NON-INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF EXAMINATION FEES APP-01 Rev. 00 February 25, 2015 Page 1 of 1
