PRC Form No.
001 Republic of the Philippines NOT FOR SALE
(Revised September
2010)
PROFESSIONAL REGULATION COMMISSION REPRODUCTION
IS ALLOWED
Application No.
Manila
PRC Central Office : APPLICATION DIVISION P. Paredes St., Sampaloc 1008 Manila,
Philippines Website : www.prc.gov.ph
Tel. No.: (63-2) - 314-00-
Paste here
27 yourrecen
First Timer APPLICATION FORM passport
t size
Repeater with
pictureCOMPLETE
Name
Conditioned Name of Examination inTag
plain
Absent Date of Examination backgroun
white
d
Date (mm/dd/yy) Place of Examination Scanned/
picture not
NOTICE : This application must be filled out in INK and in the applicant’s handwriting. All supporting documents shall become part of Photocopied
the records of the Commission. All applications must be filed PERSONALLY by the applicant. accepted
Maiden Surname (for married female only)
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City) Zip Code RURBAN Code (Town/City, Prov)
Gender MaleFemale CitizenshipContact Numbers (Landline & Mobile) E-mail Address
Filipino Others ________________
Civil Status Date of Birth (mm/dd/yy) Place of Birth (City/Town,Prov.) RURBAN Code (Town/City,
Prov)
Single Married Widow/er
Spouse’s Name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
PART I -PERSONAL
INFORMATION
SURNAME GIVEN NAME/S MIDDLE NAME
HAVE YOU EVER BEEN CHARGED AND CONVICTED BY FINAL JUDGEMENT BY ANY COURT OF JUSTICE/MILITARY
TRIBUNAL OR
ADMINISTRATIVE BODY
? 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
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
Other Higher Educational Attainment Address/Location of School Date Graduated PRC SCHOOL
Name of School (mm/dd/yy) Code
PART III - PREVIOUS PRC LICENSURE EXAMINATION/S TAKEN (Last
Three Exams)
Place of Date Taken Result of Examination (pls
Name of Examination Examination (mm/yy) Rating check) Exam No Verified by
Passed Failed Cond.
Review School/Center Self-Review School-Based Review Others (specify
name)
STATUS CODES (refer at the 1.) Examination Type (EX Code) 2.) Number of Times Taken (NX Code)
back)
I HEREBY CERTIFY that the information and/or ACTION TAKEN BY THE APPLICATION PROCESSOR
statements in this application including the supporting ISSUANCE of the FOLLOWING FORMS
documents submitted in support thereof are all true and NOTICE OF ADMISSIONPERMANENT
correct of my own knowledge, and that I am fully aware that EXAMINATION &
any false information or statement in this application or in its (NOA)REGISTRATION RECORD CARD (PERRC)
attachments shall render me liable for criminal prosecution
and /or administrative sanction. REMARKS
RIGHT THUMBMARK
PROCESSOR Date
Signature of
Applicant
Date
Accomplished ACTION TAKEN BY THE LEGAL OFFICER (if applicable)
Subscribed and sworn to before me this __________ REMARKS
day of _____________ 20_____ at ______________. Affiant
applicant exhibited to me his/her Community Tax
LEGAL OFFICER Date
Certificate No.
_______________________ issued at
________________________
ACTION TAKEN BY THE BOARD
APPROVED DISAPPROVED CONDITIONAL
REMARKS
CHAIRMAN/MEMBER Date
Documen
tary ACTION TAKEN BY THE CASHIER
Stam PRC ADMINISTERING
p AMOUNT PAID OFFICIAL
OFFICER
Administration of Oath is RECEIPT NO.
(Office
FREEOrder No.2009-377
2009-379
& CASHIERDate
both dated September 3,
2009)
on __________________.
ACTION TAKEN BY THE ISSUING OFFICER
REMARKS
ISSUING OFFICER Date
IMPORTANT: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL
MEAN NON INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF
EXAMINATION FEES.
PLEASE READ THE REQUIREMENTS, STEPS and OTHER REMINDERS at the
BACK
CHECKLIST OF REQUIREMENTS (ORIGINAL and
PHOTOCOPY)
NSO Birth Certificate
Daily Time Record (Pharmacist)
NSO Marriage Contract (female married applicant)Detailed Description of Equipment (CPM)
Transcript of Records with degree/course, exact date of graduation , SpecialDiploma, Logbook, Mentor’s PRC
License,
Order (S.O)/exemption/accreditation/deregulation status, SCANNEDPTR & IAPOA (Architect)
PICTURE and remarks “FOR BOARD EXAMINATION PURPOSES ONLY”
High School Diploma (RME)
Four (4) pcs Passport Size (1 1/2 x 1 1/2) colored pictures with full name tag
NBI Clearance (Arch, Chem Eng, CPA,
Community Tax Certificate (cedula)
Criminologist, Dentist, Dental Hygienist,
Any valid IDENTIFICATION CARD Dental Technician, Vet Med, Guidance &
Counselling)
Affidavit of Competency (CPM)
Police & Court Clearances (Criminologist)
Certificate of Registration/PRC License (Nurse-Midwife, Ocular Pharm)
Record of Deliveries Handled (Midwife)
Certificate of 1,000 Case Hours (Social Worker)
Record of OR-DR Cases (Nurse)
Certificate of Experience (CPM, Env’tal Planner, Landscape Arch, Master
Plumber)Refresher Course (CPA, Dentist, Med Tech
PT & OT, Physician, Pharm, Opto)
Cerificate of Special Pharmacology Course (Ocular Pharmacology)
Summary of Related Learning Experience
Certificate of Employment (CPM, Env’tal Planner, Landscape Arch, Master
Plumber)Others CHED Permit/ Recognition for New
Schools and / or New Programs
Certificate of Internship/OJT (Physician, Pharm, PT & OT, Dental Tech &
Hygienist)
for BLURRED NSO Birth Cert/Marriage
*Certification of Good Moral Character [Agri (2), Crim (3), Fishery Tech (1),
Forester (2), Lib.(2), Env’tal P. (1)] Certificate. it MUST BE SUPPORTED BY the
Certification of Mine and Mill Practice (Mining Engineer) LOCAL CIVIL REGISTRY Birth Certificate Copy of Thesis - Title Page &
and Marriage Certificate.
Approval Sheet (Chemist)
*Certification of Good Moral Character - must come from any and/or all of the
following : Barangay, Church, School, and Employer
STEPS in APPLYING for LICENSURE EXAMINATION
STEP 1: Secure Application Form at the Public Assistance Counter or download from www.prc.gov.ph STEP 2:
Fill-out Application Form then proceed to Customer Service Center for documentary stamp and Coop Store for the
window mailing envelope with postage stamp.
STEP 3: Processing Counters (windows 5,6,7,8) or other designated counters for evaluation and assessment .
STEP 4: Pay examination fee at the Cashier’s Counters (windows 1,2,3,4) or other designated counters. STEP 5:
Accomplish the Permanent Examination and Registration and Record Card (PERRC) and Notice of Admission
(NOA).
STEP 6: SUBMIT ALL DOCUMENTS at the Issuance Counters (windows 9,10,11,12) or other designated counters.
STEP 7: Verify your school assignment at the PRC Office or visit www.prc.gov.ph 2-3 working days before the first
day of exam .
NO APPLICATIONS SHALL BE ACCEPTED AFTER THE DEADLINE
RURBAN CODES/SCHOOL CODES/COURSE CODES/BOARD CODES/STATUS CODES
1. Refer to the MASTERLIST of ADDRESS/RURBAN CODES posted at the premises of the filing center for the CODES of the
Town, City or Province of your Residence and Postal Address and Place of Birth . This is different from the ZIP CODE.
2. Refer to the MASTERLIST of SCHOOL CODES also posted at the filing center for the School /College/University and
Location
3. Refer to the MASTERLIST of COURSE CODES for the Course Code.
4. For STATUS CODES, use the following:
a. EX CODE - Examination Type Code
Print “1” for Complete/First Timer Print “4” for Theory Only Print “7” for Finals
Print “2” for Repeaters Print “5” for Practical Only Print “8” for Finals with Prelims Print “3” for
Removal/Conditioned Print “6” for Prelims
b. NX CODE - Number of Times Taken
Print “0” for None
Print “1” for Once
Print “2” for Twice... and so on
I M P O R T A N T
1. Keep and bring your Notice of Admission with Official Receipt.
2. Bring pencils (No. 1 or 2), ballpen (with black ink only), one piece (1) big brown envelope, one long transparent plastic
envelope.
3. Report to your school assignment before 6:30 a. m. on examination days. Late examinees will not be admitted . This
will mean forfeiture of examination fee.
4. DO NOT BRING HOME THIS APPLICATION FORM. This Form MUST BE ACCOMPLISHED & SUBMITTED to the
Application Division in order for your name to be included in the List of Examinees.
PRC Form No. 001 (Revised September 2010) O-LIC/APPLIC
