APPOINTMENT DATE: Jul 31, 2019 (04:00 PM TO 05:00 PM) - PRC Butuan

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)

REFERENCE NO: EXQ4MRHGLQ4L
Application No.
OR: - | AMOUNT: PHP -
-
First Timer PROFESSIONAL TEACHER
Name of Examination Secondary(English)
_________________________________
X Repeater
Conditioned Date of Examination September 29, 2019
_________________________________
Absent
Place of Examination BUTUAN CITY
_________________________________
________________
07/30/2019
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
DINGDING ALMA GUIRITAN
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
LADGARON CLAVER, SURIGAO DEL NORTE
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
Male X Female X Filipino Others______ 0938 740 2510 alma_dingding@yahoo.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 07/25/1982 GIGAQUIT, SURIGAO DEL NORTE 106711
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
BONIFACIO P. DINGDING / FILIPINO ERMELINDA G. DINGDING / 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
NORTHEASTERN MINDANAO COLL. SURIGAO CITY, SURIGAO DEL NORTE 0840
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BACHELOR OF SECONDARY EDUCATION 2017 03/16/2006 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 - 04/2009 71.20 X
PROFESSIONAL TEACHER - 09/2008 59.00 X
PROFESSIONAL TEACHER - 08/2006 60.00 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. ______________________________________________________________________________

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
PASSPORT NUMBER: EC5460293
________________________issued PE KUWAIT
at _______________
REMARKS ______________________________________________
on _____________.
09/24/2015 ______________________________________________________________________________
DOCUMENTARY STAMP

CHAIRMAN/ MEMBER ______________________ Date __________

_______________________________
PRC ADMINISTERING OFFICER
Administration of Oath Is Free
(Office Order No. 2009-377 & 2009-379
both dated September 3, 2009)
____________________________________________________________
ACTION TAKEN BY THE CASHIER
AMOUNT PAID ____________
- OFFICIAL RECEIPT NO. _____________
-
PRC - CASHIER
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 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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