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NOT FOR SALE (REPRODUCTION IS ALLOWED)
First Timer
Repeater Conditioned
Absent
________________
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
Maiden Surname (for married female only)
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
Gender
Male Female
Citizenship
Filipino Others______
Contact numbers (Landline & Mobile)
E-mail Address
Civil Status
Single Married Widow/er
Date of Birth(mm/dd/yy)
Place of Birth (City/Town,Prov)
RURBAN Code(Town/City,Prov)
Spouse’s name & Citizenship
Father’s Name & Citizenship
Mother’s Name & Citizenship
HAVE YOU EVER BEEN CHARGED AND CONVICTED BY FINAL JUDGEMENT BY ANY COURT OF JUSTICE/MILITARY TRIBUNAL OR
ADMINISTRATIVE BODY? 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
Degree/Course Obtained
PRC COURSE Code
Date Graduated (mm/dd/yy)
PRC Board Code
Other Higher Educational Attainment
Name of School
Address/Location of School
Date Graduated
(mm/dd/yy)
PRC SCHOOL
CODE
PART III – PREVIOUS PRC LICENSURE EXAMINATION/S TAKEN (Last Three Exams)
Name of Examination
Place of
Examination
Date Taken
(mm/yy)
Rating
Result of Examination (pls check)
Exam No.
Verified by
Passed
Failed
Cond.
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
Professional Regulation Commission
APPLICATION FORM
Name of Examination
_________________________________
Date of Examination
_________________________________
Place of Examination
_________________________________
ACTION TAKEN BY THE APPLICATION PROCESSOR
ISSUANCE of the FOLOWING FORMS
NOTICE OF ADMISSION PERMANENT EXAMINATION &
(NOA) REGISTRATION RECORD CARD (PERRC)
REMARKS ______________________________________________
______________________________________________________________________________
PROCESSOR_____________________________ Date ___________
____________________________________________________________
ACTION TAKEN BY LEGAL OFFICER (if applicable)
REMARKS ______________________________________________
______________________________________________________________________________
LEGAL OFFICER __________________________ Date ___________
____________________________________________________________
ACTION TAKEN BY THE BOARD
APPROVED DISAPPROVED CONDITIONAL
REMARKS ______________________________________________
______________________________________________________________________________
CHAIRMAN/ MEMBER ______________________ Date __________
____________________________________________________________
ACTION TAKEN BY THE CASHIER
AMOUNT PAID ____________ OFFICIAL RECEIPT NO. _____________
CASHIER _________________________________ Date __________
____________________________________________________________
ACTION TAKEN BY THE ISSUING OFFICER
REMARKS _______________________________________________
______________________________________________________________________________
ISSUING OFFICER ________________________ Date __________
Application No.
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.
_______________________
Signature of Applicant
_______________________
Date Accomplished
Subscribed and sworn to before me this __________day of
_________20____at__________. Affiant applicant exhibited
to me his / her Community Tax Certificate No.
________________________issued at _______________
on _____________.
RIGHT THUMBMARK
_______________________________
PRC ADMINISTERING OFFICER
Administration of Oath Is Free
(Office Order No. 2009-377 & 2009-379
both dated September 3, 2009)
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
DOCUMENTARY STAMP
000334
X
APPOINTMENT DATE: Feb 03, 2020 (10:00 AM TO 11:00 AM) - Robinsons Place Ormoc
REFERENCE NO: EXYA3ZYWA7O9
OR: 9460719 | AMOUNT: PHP 600
01/31/2020
REGISTERED MASTER ELECTRICIAN
APRIL 16, 2020
Cebu
AYING EDWARD ROY CAPUYAN
PUROK 5/PROPER 1/BARANGAY PUERTO BELLO MERIDA, LEYTE
X X 09300468634 [email protected]
X09/14/1994 MERIDA, LEYTE 083736
ROGELIO S. AYING / FILIPINO EDUVIGES C. AYING / FILIPINO
X
EASTERN VISAYAS STATE UNIV. (FOR. L.I.T.)-ORMOC CAMPUS ORMOC CITY, LEYTE 1755
BS IN ELECTRICAL ENGINEERING 3047 01/27/2020 1150
REGISTERED MASTER ELECTRICIAN -09/2021 .00
1
SCHOOL ID EVSU
06/15/2016
600 9460719
PRC - CASHIER 02/03/2020