APPOINTMENT DATE: Sep 19, 2019 (02:00 PM TO 03:00 PM) - Philippine International Convention Center (PICC)
Professional Regulation Commission
APPLICATION FORM
NOT FOR SALE (REPRODUCTION IS ALLOWED)
REFERENCE NO: EXE3HGRWQGGV
Application No.
OR: - | AMOUNT: PHP -
-
X First Timer
Repeater Name of Examination ELECTRONICS ENGINEER
_________________________________
Conditioned Date of Examination October 19 & 20, 2019
_________________________________
Absent
Place of Examination Manila
_________________________________
________________
09/10/2019
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
BALALA TRISTAN RUEL REGALADO
Maiden Surname (for married female only)
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
359 BE ILANG ILANG ST. LIGAS MALOLOS, BULACAN
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
X Male Female X Filipino Others______ 09612841591 EngrBalala2019@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 03/10/1998 MALOLOS, BULACAN 031410
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
RUEL T. BALALA / FILIPINO LEAH R. BALALA / 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
BULACAN STATE UNIVERSITY (for.BCAT)-MALOLOS MALOLOS, BULACAN 0007
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BS IN ELECTRONICS & COMMUNICATIONS ENG'G 3049 06/11/2019 1202
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
05016142
________________________issued LIGAS MALOLOS, BULACAN
at _______________
REMARKS ______________________________________________
on _____________.
09/03/2019 ______________________________________________________________________________
DOCUMENTARY STAMP
CHAIRMAN/ MEMBER ______________________ Date __________
____________________________________________________________
ACTION TAKEN BY THE CASHIER
_______________________________
PRC ADMINISTERING OFFICER AMOUNT PAID ____________
- OFFICIAL RECEIPT NO. _____________
-
PRC - CASHIER
CASHIER _________________________________ -
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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