REFERENCE NO: CEA3EI77OW0N | OR: E2023-06-05232733 | Amount: PHP 150.
00
Jun 15, 2023 (10:00 AM TO 11:00 AM) - Robinsons Place Pangasinan
NOTE: This appointment date might be different to the date of claiming of the requested authenticated documents
Professional Regulation Commission
ACTION SHEET FOR AUTHENTICATION
DATE FILED: Jun 14, 2023 Please underline: MALE/FEMALE
_______
NAME: BUSEL, MARY ANN MARQUEZ
_____________________________________________________________________________________________
Last Name First Name Middle Name Married Name
PROFESSION: PROFESSIONAL TEACHER REGISTRATION NO.: 1641890 REGISTRATION DATE: 06/06/2018
(For Professional Teacher, please tick [ ] Elementary [ ] Secondary)
VALIDITY DATE OF PROFESSIONAL IDENTIFICATION CARD (PIC): 06/05/2024 TEL./CP NO.: 09482658423
PLEASE CHECK BOX FOR TYPE OF DOCUMENT TO BE AUTHENTICATED:
CERTIFICATE OF REGISTRATION (COR) NO. OF COPIES PURPOSE:
CERTIFICATION OF BOARD RATING NO. OF COPIES LOCAL
CERTIFICATION OF GOOD STANDING NO. OF COPIES ABROAD
CERTIFICATION OF PASSING NO. OF COPIES LEGAL
X PROFESSIONAL IDENTIFICATION CARD NO. OF COPIES 2 STATEBOARD
REPORT OF RATINGS NO. OF COPIES OTHERS
OTHERS NO. OF COPIES
FOR PRC PROCESSING
150.00
Amount: ____________________________ Processed by: Prepared by:
_
E2023-06-05232733
O. R. No.: ___________________________
06/14/2023 ___________________________________ ____________________________________
Date: ___________________________
Signature over printed name Signature over printed name
PAYMAYA-GCASH
Issued by: ___________________________
- Date: ______________________________ Date: ________________________________
Date due: __________________________
NOTE: AUTHENTICATION REQUIRES A VALID PROFESSIONAL IDENTIFICATION CARD.
AUTHENTICATION CLAIM SLIP
PLEASE FILL OUT THIS CLAIM SLIP
NAME: BUSEL, MARY ANN MARQUEZ
_____________________________________ PROFESSION: PROFESSIONAL TEACHER
___________________________
1641890
REGISTRATION NO.: _____________________________________ 06/06/2018
REGISTRATION DATE: ___________________________
DATE FILED: Jun 14, 2023
_____________________________________ -
DATE DUE: _____________________________________
PLEASE PRESENT THIS SLIP TO CLAIM DOCUMENTS AT ______________ ON ______________________. PRC REGISTERED
REPRESENTATIVE SHOULD PRESENT ANY VALID GOVERNMENT-ISSUED ID AND AUTHORIZATION LETTER; IF NOT REGISTERED
PROFESSIONAL, PRESENT SPECIAL POWER OF ATTORNEY(SPA)AND ANY VALID GOVERNMENT-ISSUED ID.
REGISTRATION OFFICER
IMPORTANT NOTES:
1. PLEASE ENSURE THAT YOU BRING THE ORIGINAL DOCUMENT YOU
WISH TO HAVE AUTHENTICATED.
2. ADDITIONALLY, PLEASE REMEMBER TO BRING THE CORRESPONDING
NUMBER OF PHOTOCOPIES OF THE SAME DOCUMENT THAT REQUIRE
AUTHENTICATION.
PRD-07
Rev. 00
October 16, 2020
Page 1 of 2
