APPOINTMENT DATE: Jul 26, 2019 (11:00 AM TO 12:00 PM) - OSSCO Nueva Ecija

Professional Regulation Commission

APPLICATION FORM

REFERENCE NO: EXLO9QCGCT5R NOT FOR SALE (REPRODUCTION IS ALLOWED)

Application No.
- OR: - | AMOUNT: PHP -
First Timer PROFESSIONAL TEACHER
X
Repeater Name of Examination Secondary(English)
Conditioned Date of Examination September 29, 2019
Absent Place of Examination Baguio
07/20/2019
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
PADRE PRINCESS CYNEL PEREZ
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
#487, PUROK 7, SAN JOSE JAEN, NUEVA ECIJA
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
Male X Female X Filipino Others______ 09668299693 pcynel22@gmail.com

Civil Status Date of Birth(mm/dd/yy) Place of Birth (City/Town,Prov) RURBAN Code(Town/City,Prov)

X Single Married Widow/er 09/22/1997 JAEN, NUEVA ECIJA 034912

Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
NILO D. PADRE / FILIPINO PRISCILLA Y. PADRE / 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
NUEVA ECIJA UNIVERSITY OF SCIENCE & TECHNOLOGY-SAN ISIDRO)SAN ISIDRO, NUEVA ECIJA 0052
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BACHELOR OF SECONDARY EDUCATION 2017 05/30/2019 4000
Other Higher Educational Attainment Name of School Address/Location of School Date Graduated PRC SCHOOL
(mm/dd/yy CODE
)

PART III – PREVIOUS PRC LICENSURE EXAMINATION/S TAKEN (Last Three Exams)
Name of Examination Place of Date Taken Rating Result of Examination (pls check) Exam No. Verified by
Examination (mm/yy) 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 0

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
NOTICE OF ADMISSION PERMANENT EXAMINATION &
correct to my own knowledge, and that I am fully aware that (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
06874389 issued at JAEN, NUEVA ECIJA REMARKS ______________________________________________
on 07/02/2019 . ______________________________________________________________________________
STAMP

_______________________________
CHAIRMAN/ MEMBER ______________________ Date __________
____________________________________________________________
ACTION TAKEN BY THE CASHIER
DOCUMENTARY

AMOUNT PAID - OFFICIAL RECEIPT NO. -

PRC ADMINISTERING OFFICER
Administration of Oath Is Free
(Office Order No. 2009-377 & 2009-379
both dated September 3, 2009)
CASHIER PRC - CASHIER Date -
____________________________________________________________
ACTION TAKEN BY THE ISSUING OFFICER
REMARKS _______________________________________________
______________________________________________________________________________
ISSUING OFFICER ________________________ Date __________

IMPORTANT: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL MEAN NON- APP-01
INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF EXAMINATION FEES Rev. 00
February 25, 2015
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