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    Professional Regulation Commission

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    Klyde Bacbac
    Aileen Mablay is applying to renew her Professional Identification Card (PIC) as a midwife. Her current PIC will expire on July 20, 2027. She declares that the information provided is correct and understands any false statements could lead to rejection or cancellation of her application or PIC. As she did not fully comply with continuing professional development credit requirements, she undertakes to submit the remaining credits needed for the next renewal of her PIC.

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    Professional Regulation Commission

    Uploaded by

    Klyde Bacbac
    14 views1 page
    Aileen Mablay is applying to renew her Professional Identification Card (PIC) as a midwife. Her current PIC will expire on July 20, 2027. She declares that the information provided is correct and understands any false statements could lead to rejection or cancellation of her application or PIC. As she did not fully comply with continuing professional development credit requirements, she undertakes to submit the remaining credits needed for the next renewal of her PIC.

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    Aileen Mablay is applying to renew her Professional Identification Card (PIC) as a midwife. Her current PIC will expire on July 20, 2027. She declares that the information provided is correct and understands any false statements could lead to rejection or cancellation of her application or PIC. As she did not fully comply with continuing professional development credit requirements, she undertakes to submit the remaining credits needed for the next renewal of her PIC.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    14 views1 page

    Professional Regulation Commission

    Uploaded by

    Klyde Bacbac
    Aileen Mablay is applying to renew her Professional Identification Card (PIC) as a midwife. Her current PIC will expire on July 20, 2027. She declares that the information provided is correct and understands any false statements could lead to rejection or cancellation of her application or PIC. As she did not fully comply with continuing professional development credit requirements, she undertakes to submit the remaining credits needed for the next renewal of her PIC.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    TIME RECEIVED:

    TIME RELEASED:

    Professional Regulation Commission

    APPLICATION FOR PROFESSIONAL IDENTIFICATION CARD (PIC)

    NOT FOR SALE (REPRODUCTION IS ALLOWED)

    APPOINTMENT DATE: December 28, 2023 (01:00 PM TO 02:00 PM) - PRC Baguio
    REFERENCE NO: REGMQDDKAL83 | OR: E2023-12-06770680 | Amount: PHP 420.00
    NAME: MABLAY, AILEEN BUTANGEN

    CITIZENSHIP: FILIPINO BIRTHDATE: July 20, 1996

    PERMANENT MAILING ADDRESS: N/A MINAC BALLAY KABAYAN, BENGUET


    TEL. NO. / CP NO.: 09075816419 EMAIL ADDRESS: aileenmablay1@gmail.com
    SCHOOL GRADUATED: CORDILLERA CAREER DEVELOPMENT COLLEGE DATE GRADUATED: May 20, 2017
    REGISTRATION DATE: November 15, 2018 EXPIRATION DATE: July 20, 2027
    PROFESSION: MIDWIFE LICENSE NO.: 0177241

    DECLARATION AND ATTESTATION

    I am aware and I give my consent to the collection of the data required by this application form and
    the taking of my photograph, and if applicable, the taking of my fingerprints.

    I further attest that all particulars and supporting documents provided by me are correct and
    complete. I am aware that any false statement or fraudulent document will lead to the rejection of my
    application or to the cancellation of my PIC already issued, and may also render me liable under applicable
    administrative and criminal laws.

    SIGNATURE OF LICENSEE

    UNDERTAKING

    (To be filled up by professionals, except for Real Estate Practitioners, who failed to comply with the
    required CPD Credit Units for the renewal of Professional Identification Card)

    For this compliance period, I am submitting CPD units of the total required CPD Credit units. I
    hereby undertake to submit the balance of CPD credit units in addition to the required CPD units (or a
    total of units) for the next renewal of my PIC. I understand that in the event I fail to comply, my PIC will
    not be renewed.

    SIGNATURE OF LICENSEE

    NOTE:
    1) ALL REAL ESTATE PRACTITIONERS CANNOT AVAIL THE UNDERTAKING AND HAVE TO
    PROVIDE PROOF OF COMPLIANCE WITH CPD PRIOR TO RENEWAL OF PIC PURSUANT TO
    SECTION 17, ARTICLE III OF REPUBLIC ACT NO. 9646 OR THE REAL ESTATE SERVICE ACT
    OF THE PHILIPPINES AND BOARD RESOLUTION NO. 49, S. 2015.
    2) REPRESENTATIVE OF THE PROFESSIONAL APPLYING FOR ISSUANCE OF PROFESSIONAL
    IDENTIFICATION CARD (PIC) MUST SUBMIT:
    a) THE PRESCRIBED AUTHORIZATION LETTER AND PHOTOCOPY OF PROFESSIONAL
    IDENTIFICATION CARD (PIC) OF THE REPRESENTATIVE AND EXPIRED PIC OF THE
    PRFESSIONAL; OR
    b) SPECIAL POWER OF ATTORNEY (SPA) AND PHOTOCOPY OF ANY VALID GOVERNMENT
    ISSUED IDENTIFICATION CARD (ID) OF THE REPRESENTATIVE AND THE PROFESSIONAL
    3) STRICTLY FOLLOW THE APPOINTMENT DATE ON RENEWAL OF PROFESSIONAL
    IDENTIFICATION CARD (PIC).

    REG-03
    Rev. 02
    September 15, 2017
    Page 1 of 1

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