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Application Form: Professional Regulation Commission

The document is an application form for a pharmacist licensure exam. It contains personal information of the applicant such as name, address, education history. It details the exam date, place, and amount paid for the application.

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amante jerome
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93 views

Application Form: Professional Regulation Commission

The document is an application form for a pharmacist licensure exam. It contains personal information of the applicant such as name, address, education history. It details the exam date, place, and amount paid for the application.

Uploaded by

amante jerome
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPOINTMENT DATE: Jun 20, 2018 (PM) - Robinson?

s Place Manila | OR: 13829947 | AMOUNT: PHP 900

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)


Application No.
004441
X First Timer
Repeater Name of Examination PHARMACIST
_________________________________
Conditioned Date of Examination August 4 - 5, 2018
_________________________________
Absent
Place of Examination Manila
_________________________________
________________
06/15/2018
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
SISON HAZEL MAE FERRER
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
143 PINEAPPLE ROAD, DEL MONTE, POTRERO, MALABON CITY BOTOLAN, ZAMBALES
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
Male X Female X Filipino Others______ 09262828760 / 2540944 hazelsison1001@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 10/01/1995 IBA, ZAMBALES 037105
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
ROMEO JOSE A. SISON JR / FILIPINO ALLEN U. FERRER / 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
OUR LADY OF FATIMA UNIVERSITY-VALENZUELA VALENZUELA, METRO MANILA 0163
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BS IN PHARMACY 4023 04/22/2018 2810
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.

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
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
S250JHAE59-MA30430276
________________________issued UN AVENUE
at _______________
REMARKS ______________________________________________
on _____________.
05/06/2018 ______________________________________________________________________________
DOCUMENTARY STAMP

CHAIRMAN/ MEMBER ______________________ Date __________


____________________________________________________________
ACTION TAKEN BY THE CASHIER
_______________________________
PRC ADMINISTERING OFFICER AMOUNT PAID ____________
900 OFFICIAL RECEIPT NO. _____________
13829947
PRC
CASHIER _________________________________ 06/18/2018
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
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