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    Application Form

    Uploaded by

    Gavin Malala

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Application Form

    Uploaded by

    Gavin Malala
    3 views1 page

    Copyright

    © © All Rights Reserved

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    Copyright:

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    3 views1 page

    Application Form

    Uploaded by

    Gavin Malala

    Copyright:

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

    APPOINTMENT DATE: Jul 14, 2023 (05:00 PM TO 06:00 PM) - Robinsons Dasmariñas

    Professional Regulation Commission

    APPLICATION FORM

    NOT FOR SALE (REPRODUCTION IS ALLOWED)


    REFERENCE NO: EXBMBW9IYOVV
    Application No.
    OR: E2023-07-05494215 | AMOUNT: PHP 900.00
    565125
    X First Timer PROFESSIONAL TEACHER
    Repeater Name of Examination Secondary(Science)
    _________________________________
    Conditioned Date of Examination SEPTEMBER 24, 2023
    _________________________________
    Absent
    Place of Examination Manila
    _________________________________
    ________________
    07/08/2023
    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
    TABUZO CATHRINE DENISE CRISOSTOMO
    Maiden Surname (for married female only)

    Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
    BLK 27 LOT 10 STA. MARIA SAN GABRIEL GEN. MARIANO ALVAREZ, CAVITE
    Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
    Male X Female X Filipino Others______ 09562735283 cathrinedenisetabuzo@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 06/28/1999 PACO, MANILA 043911
    Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
    BERNARDO A. TABUZO / FILIPINO ROSARIO C. TABUZO / 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
    NATIONAL TEACHER'S COLLEGE 629 J. NEPOMUCENO ST., QUIAPO, MANILA 0470
    Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
    BACHELOR OF SECONDARY EDUCATION 2017 07/17/2021 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 - 09/2023 85.60 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 1

    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
    D53220305771 P
    ________________________issued CAV-DS
    at _______________
    REMARKS ______________________________________________
    on _____________.
    06/08/2022 ______________________________________________________________________________
    DOCUMENTARY STAMP

    CHAIRMAN/ MEMBER ______________________ Date __________


    ____________________________________________________________
    ACTION TAKEN BY THE CASHIER
    _______________________________
    PRC ADMINISTERING OFFICER AMOUNT PAID ____________
    900.00 OFFICIAL RECEIPT NO.E2023-07-05494215
    _____________
    Paymaya - Gcash Payment
    CASHIER _________________________________ 07/08/2023
    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
    Page 1 of 1

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