APPOINTMENT DATE: Oct 17, 2019 (11:00 AM TO 12:00 PM) - Robinsons General Santos

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)

REFERENCE NO: EXPG1CGV3ABS
Application No.
OR: - | AMOUNT: PHP -
-
First Timer
Name of Examination NURSE
_________________________________
X Repeater
Conditioned Date of Examination November 16 & 17, 2019
_________________________________
Absent
Place of Examination Davao
_________________________________
________________
10/01/2019
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
GUIAMAN NORSALAM SAMBOLAWAN
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
DAPANTIS, RAJAH BUAYAN MAGUINDANAO SULTAN SA BARONGIS, MAGUINDANAO
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
Male X Female X Filipino Others______ 09353617426 norsambolawan12@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 04/12/1987 SULTAN SA BARONGIS, MAGUINDANAO 123813
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
SAMBUTUAN U. GUIAMAN / FILIPINO LINDA S. GUIAMAN / 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
DR. DOMINGO B. TAMONDONG MEM. SCH., INC. SCH. OF MIDWIFERY
ALA, ESPERANZA, SULTAN KUDARAT 0478
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BS IN NURSING 4018 03/31/2010 2600
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.
NURSE - 11/2017 57.00 X
NURSE - 12/2013 50.20 X
NURSE - 12/2011 52.80 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
CC12016 20087798 DAPANTIS,
________________________issued at RAJAH BUAYAN MAGUINDANAO
_______________
REMARKS ______________________________________________
on _____________.
10/01/2019 ______________________________________________________________________________
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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