Professional Regulation Commission

PERSONAL DATA SHEET OF NOMINEE

THIS FORM SHOULD BE ACCOMPLISHED IN TRIPLICATE. ANY FALSE

STATEMENT OR INFORMATION HEREIN SHALL DEBAR THE NOMINEE FROM
BEING RECOMMENDED FOR APPOINTMENT AND POSSIBLE CRIMINAL 1X1
PROSECUTION MAY BE INSTITUTED AGAINST HIM/HER INCLUDING THE PICTURE
REVOCATION OF LICENSE TO PRACTICE HIS/HER PROFESSION.

BOARD TO WHICH NOMINATED NOMINATED/RECOMMENDED BY:

A. PERSONAL DATA
FULL NAME:_________________________________________________________________________________
(Last Name, First Name, Middle Name)
DATE OF BIRTH: ____________________ PLACE OF BIRTH: ____________________ GENDER: ____________
TIN: ___________________ GSIS/SSS NUMBER: ___________________ RELIGION: ______________________
OCCUPATION/PROFESSION: ____________________________PRC LICENSE NO.: ______________________
DATE OF ISSUANCE: _______________________ EXPIRATION DATE: _______________________
CIVIL STATUS: ____________ CITIZENSHIP: ______________ HOW ACQUIRED: ________________________
(By Birth or Naturalization)
PRESENT ADDRESS: ________________________________________ TEL. NO. _________________________
PROVINCIAL ADDRESS & TEL. NO.: ____________________________ MOBILE NO.: _____________________
OFFICIAL BUSINESS ADDRESS: _______________________________ TEL. NO.: ________________________
NAME OF SPOUSE: _____________________________ PROFESSION/OCCUPATION: ____________________
(If female, write maiden name)
OFFICE NAME, ADDRESS & TEL. NO. ____________________________________________________________

NAME OF CHILDREN AGE ADDRESS

NAME OF BROTHERS/SISTERS AGE ADDRESS

NAME OF FATHER: _____________________________ ADDRESS: ____________________________

NAME OF MOTHER: _____________________________ ADDRESS: ____________________________
(Use of maiden name)
NAME OF FATHER-IN-LAW: __________________________ ADDRESS: _________________________
NAME OF MOTHER-IN-LAW: _________________________ ADDRESS: _________________________
(Use of maiden name)

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PERSONAL DATA SHEET OF NOMINEE

B. PROVEN LEADERSHIP QUALITIES/CITATIONS/AWARDS

1. Professional associations of which you are an active member.

Name of Association Position Held Inclusive Period

2. Civic, social and/or religious organizations of which you are an active member.

Name of Organization Position Held Inclusive Period

3. Honors, awards and citations given by reputable organizations for demonstrated leadership
qualities.

Description Awarded by Date

4. Other information, if any, showing evidence of your proven leadership qualities.

C. PROFESSIONAL COMPETENCE AND EXPERIENCE

1. Formal educational background

Academic Degree(s) Name of School Date conferred Honor or

or units earned or earned Distinctions

2. Licensure Examination/s Passed

Name of Examination Date Taken Rating Rank if among Number of times

topnotchers taken

3. Special studies, scholarship grants, etc.

Sponsor Description of Courses Institution Attended Inclusive Period

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PERSONAL DATA SHEET OF NOMINEE

4. Participation in continuing professional education programs

Nature of Program Conducted by Nominees role* Inclusive Period

* Resource person, speaker, etc.

5. Research activities undertaken

Research Title Inclusive Period Other Relevant Information

6. Professional books and/or articles published

Title Date of Publication Name of Publication and

Publisher

D. PROFESSIONAL PRACTICE OR EMPLOYMENT

1. Professional practice

Name of Firm, Agency or Organization Position Held Inclusive Period

2. Describe briefly the nature of professional work undertaken

3. Teaching experience

Name and Location of Education Institution Subjects Taught Inclusive Period

4. Travel/s abroad for professional growth

Countries and Institution visited Purpose Inclusive Period

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PERSONAL DATA SHEET OF NOMINEE

5. Other information, if any, showing evidence of your professional practice

and employment

E. INTEGRITY AND COMMITMENT TO HIGHEST PROFESSIONAL STANDARDS

1. Please write yes or no in the appropriate box.

a. Are you a member of the faculty of any school, college or university where any branch of
the profession covered by the Board for which you are proposed for membership is taught?

b. Are you connected directly or indirectly in any manner whatsoever with any review center
or school preparing examinees to take the licensure examination given by the Board for
which you are proposed for membership?

c. Is any immediate member of your family a member of any faculty of any school, college or
university where any branch of the profession covered by the Board for which you are
proposed for appointment is being taught?

d. Do you hold any pecuniary interest in any school, college or university offering the course
covered by the Board for which you are proposed for appointment?

e. Have you ever been accused of, indicted or tried for violation of any law, ordinance or
regulation?

f. If you are or have been in the government service, were you ever the subject of any
disciplinary action?

If your answer is YES, state fully the nature of the offense, the date and the outcome.
Please attach herewith a copy of the decision.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
____________________________________________________________

2. Professional reference (clients, employers, etc. who can attest to nominees professional
competence and are not related by consanguinity or affinity to him/her).

Name/Position Address Contact No.

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PERSONAL DATA SHEET OF NOMINEE

3. On a separate sheet (limited to one page), please state your view on:

a. How the integrity of the professional examination can be maintained?

b. How the highest degree of ethical and technical standards can be promoted in your
profession?

F. TIME, CAPACITY AND CAPABILITY TO PERFORM DUTIES AND FULFILL

OBLIGATIONS AS BOARD MEMBER

1. Please write yes or no in the appropriate box.

a. Will you have time for the performance of your duties as member of the regulatory board?

Such as:

Rating your examination papers within the time allotted by the PRC?

Attending the regular monthly or special meetings of the Board in PRC?

Inspecting or performing visitorial functions of schools, plants or places of work of

professionals?

b. Can you come very early in the morning, if necessary, to attend to the printing and
mimeographing of your examination questions? Or be assigned in the province if
examinations are held any place in Luzon, Visayas and/or Mindanao?

c. Will you commit yourself to the duties and obligations of a government officer or
employee, adhere to the rules and regulations of the Commission, and remain in
your position until properly replaced, relieved or terminated?

VOUCHERS:

We hereby certify that herein nominee for membership in the regulatory board is personally
known to us to be of good reputation and moral character and that we know him/her to be fully
qualified for the position proposed for him/her.

___________________________ ___________________________
SIGNATURE SIGNATURE

___________________________ ___________________________
FULL NAME FULL NAME

PROFESSION/OCCUPATION REG. NO. PROFESSION/OCCUPATION REG. NO.

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PERSONAL DATA SHEET OF NOMINEE

CERTIFICATION AND ACKNOWLEDGMENT:

I do hereby certify that the information and data SUBSCRIBED AND SWORN TO before me on the
written by me above are true and correct to my own date and place stated hereunder. Affiant exhibited to
knowledge. me his Community Tax Certificate indicated below his
signature.

PLACE AND DATE PREPARED: PLACE AND DATE PREPARED:

SIGNATURE: SIGNATURE:

RESIDENCE CERTIFICATE: FULL NAME:

No. Date: Issued at:

Doc. Stamp Docket No. Page No. Series of TITLE OF ADMINISTERING OFFICER

COMMISSION PRIVILEGE TAX RECEIPT

EXPIRES
Number Date Issued at

IMPORTANT:

1. The accomplished form should be accompanied by an endorsement from the accredited

professional organization concerned, resume, National Bureau of Investigation (NBI),
Ombudsman, Sandiganbayan, Civil Service Commission (CSC) clearances and
medical certificate, to be filed in triplicate copies.

2. Except for the last page, all pages should be initialed by the nominee and his vouchers at
the bottom of each page.

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