APPOINTMENT DATE: Aug 28, 2019 (03:00 PM TO 04:00 PM) - PRC Cebu - Robinsons (Exam Application only)

Professional Regulation Commission

APPLICATION FORM

REFERENCE NO: EXM5BWZQKEZS

NOT FOR SALE (REPRODUCTION IS ALLOWED)
Application No.
- OR: - | AMOUNT: PHP -

X First Timer
Repeater Name of Examination CRIMINOLOGIST
Conditioned Date of Examination November 29, 30 & Dec. 1, 2019
Absent
07/10/2019 Place of Examination Cebu
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
SULLANO NICO LABAY
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
GOV.CUENCO BANILAD CEBU CITY VILLABA, LEYTE
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
X Male Female X Filipino Others 09226598485 nicosullano2789@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 10/08/1998 CEBU CITY 072217
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
NESTOR R. SULLANO / FILIPINO GRACE L. SULLANO / 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 CEBU COR. SANCIANGKO AND J. LUNA STS., CEBU CITY, CEBU0772
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BS IN CRIMINOLOGY 9002 03/20/2019 3500
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
10864952 issued at CEBU CITY REMARKS
on 07/09/2019 . _
DOCUMENTARY STAMP

CHAIRMAN/ MEMBER Date

ACTION TAKEN BY THE CASHIER

PRC ADMINISTERING OFFICER AMOUNT PAID - OFFICIAL RECEIPT NO. -
CASHIER PRC -_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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