APPOINTMENT DATE: Sep 24, 2019 (02:00 PM TO 03:00 PM) - Philippine International Convention Center (PICC)
Professional Regulation Commission
APPLICATION FORM
NOT FOR SALE (REPRODUCTION IS ALLOWED)
REFERENCE NO: EX02ATQI0WGA
Application No.
OR: 926023563558 | AMOUNT: PHP 900
004608
X First Timer
Repeater Name of Examination NURSE
_________________________________
Conditioned Date of Examination November 16 & 17, 2019
_________________________________
Absent
Place of Examination Manila
_________________________________
________________
09/18/2019
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
DE ROXAS LIMWEL JUSTINE MENDOZA
Maiden Surname (for married female only)
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
HALANG TAAL BATANGAS TAAL, BATANGAS
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
X Male Female X Filipino Others______ 09972835913 ljmdr02@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 07/27/1997 LEMERY, BATANGAS 131012
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
PANTALEON / FILIPINO ELVIRA / 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
LYCEUM OF THE PHILIPPINES UNIVERSITY-BATANGAS,INC CAPITOL SITE, BATANGAS CITY, BATANGAS 0539
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BS IN NURSING 4018 06/14/2019 2600
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
13627124
________________________issued TAAL BATANGAS
at _______________
REMARKS ______________________________________________
on _____________.
08/05/2019 ______________________________________________________________________________
DOCUMENTARY STAMP
CHAIRMAN/ MEMBER ______________________ Date __________
____________________________________________________________
ACTION TAKEN BY THE CASHIER
_______________________________
PRC ADMINISTERING OFFICER AMOUNT PAID ____________
900 OFFICIAL RECEIPT NO. _____________
926023563558
Paymaya - Mastercard
CASHIER _________________________________ 09/18/2019
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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