Application Form: Professional Regulation Commission
Application Form: Professional Regulation Commission
Application Form: Professional Regulation Commission
APPLICATION FORM
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
209 GEN. YNGENTE AVE. BRGY. TALOLONG LOPEZ, QUEZON
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
X Male Female X Filipino Others______ 09303253685 [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 12/24/1978 LOPEZ, QUEZON 135622
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
MENCHI VILLATE REGIDOR / FILIPINO LUIS REYES AZAGRA / FILIPINO ROSARIO ARENAL ESCOBIDO / 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
PHILIPPINE NORMAL UNIVERSITY- SOUTH LUZON LOPEZ, QUEZON 0506
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BACHELOR OF ELEMENTARY EDUCATION 2013 03/29/2009 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 - 09/2019 69.80 X
PROFESSIONAL TEACHER - 03/2019 73.40 X
PROFESSIONAL TEACHER - 03/2018 65.00 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 3
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. ______________________________________________________________________________
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
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