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    of 1

    APPOINTMENT DATE: Dec 27, 2023 (11:00 AM TO 12:00 PM) - PRC-Bohol

    Professional Regulation Commission

    APPLICATION FORM

    NOT FOR SALE (REPRODUCTION IS ALLOWED)


    REFERENCE NO: EXIRKGYZO9AH
    Application No.
    OR: E2023-12-06938029 | AMOUNT: PHP 900.00
    031216
    X First Timer
    Repeater Name of Examination MEDICAL TECHNOLOGIST
    _________________________________
    Conditioned Date of Examination MARCH 21 - 22, 2024
    _________________________________
    Absent
    Place of Examination Cebu
    _________________________________
    ________________
    12/23/2023
    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
    ACANTILADO RADNE MAE BARRETE
    Maiden Surname (for married female only)

    Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
    0053 PUROK CENTRO LICOLICO SEVILLA, BOHOL
    Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
    Male X Female X Filipino Others______ 09707583457 [email protected]
    Civil Status Date of Birth(mm/dd/yy) Place of Birth (City/Town,Prov) RURBAN Code(Town/City,Prov)
    X Single Married Widow/er 07/18/2001 TAGBILARAN CITY, BOHOL 071242
    Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
    RUDIVINO C. ACANTILADO / FILIPINO TERESITA B. ACANTILADO / 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
    HOLY NAME UNIVERSITY (for.DIVINE WORD-TAGBILARAN) TAGBILARAN CITY, BOHOL 0131
    Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
    BS IN MEDICAL TECHNOLOGY 4017 08/04/2023 2110
    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.
    MEDICAL TECHNOLOGIST - 03/2024 86.40 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 1

    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
    G03-22-302482
    ________________________issued TAGBILARAN CITY, BOHOL
    at _______________
    REMARKS ______________________________________________
    on _____________.
    08/11/2022 ______________________________________________________________________________
    DOCUMENTARY STAMP

    CHAIRMAN/ MEMBER ______________________ Date __________


    ____________________________________________________________
    ACTION TAKEN BY THE CASHIER
    _______________________________
    PRC ADMINISTERING OFFICER AMOUNT PAID ____________
    900.00 OFFICIAL RECEIPT NO.E2023-12-06938029
    _____________
    Paymaya - Wallet
    CASHIER _________________________________ 12/23/2023
    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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