APPOINTMENT DATE: Jul 11, 2019 (AM) - Robinson?

s Place Manila | OR: 919900733 | AMOUNT: PHP 900

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)

REFERENCE NO:
Application No.
EX51J48JDDGH
121502
First Timer PROFESSIONAL TEACHER
Name of Examination Secondary(Physical Sciences)
_________________________________
X Repeater
Conditioned Date of Examination September 29, 2019
_________________________________
Absent
Place of Examination Manila
_________________________________
________________
06/18/2019
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
ADLAWAN MARICEL QUEROBINES
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
SALVACION ST. BARGY. BAROBABAY LAVEZARES, NORTHERN SAMAR
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
Male X Female X Filipino Others______ 09055943661 sethliwan1441@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 01/27/1997 LAVEZARES, NORTHERN SAMAR 084811
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
VENANCIO L. GAYOL JR. / FILIPINO MILA Q. ADLAWAN / 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
UNIVERSITY OF EASTERN PHILIPPINES-CATARMAN UNIVERSITY TOWN, CATARMAN, NORTHERN SAMAR 0005
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BACHELOR OF SECONDARY EDUCATION 2017 04/06/2017 4000
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.
PROFESSIONAL TEACHER - 03/2019 71.60 X
PROFESSIONAL TEACHER - 09/2018 65.80 X
PROFESSIONAL TEACHER - 09/2017 69.40 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
0111-8751623-8 1031 A TANBAKAN
________________________issued RD 1 BRGY 35 CALOOCAN CITY
at _______________
REMARKS ______________________________________________
on _____________.
06/25/2018 ______________________________________________________________________________
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 ____________
900 OFFICIAL RECEIPT NO. _____________
919900733
UCPB - Over the counter
CASHIER _________________________________ 06/19/2019
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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