APPOINTMENT: Aug 05, 2025 (08:00 AM TO 09:00 AM) - BARMM-Cotabato City Offsite Service Center | REF: EXUR4JFYIDIP | OR:
E2025-07-30124984
(07/30/2025) | AMOUNT: PHP 900.00
Professional Regulation Commission
APPLICATION FORM
Application No. Passport size colored
209105
PROFESSIONAL TEACHER picture
Name of Examination _________________________________
Elementary (No Specialization) with COMPLETE
First Timer Name Tag
Date of Examination SEPTEMBER 21, 2025
_________________________________ in plain white
X Repeater
background taken
Conditioned Place of Examination
KIDAPAWAN COTABATO
_________________________________ within the last 6
Absent months
________________
07/30/2025
Date (mm/dd/yy)
PART I – PERSONAL INFORMATION
LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME
MUSA TAHA N/A KASIM
Maiden Name (for married female only)
N/A
Permanent Mailing Address (House No., Street, Village/Subd., Brgy., Town, Prov./City)
N/A POBLACION DATU PIANG DATU PIANG, MAGUINDANAO
Sex Citizenship Contact No Email Address
MALE FILIPINO n/a musataha742@gmail.com
Civil Status BirthDate (mm/dd/yyyy) Place of Birth (City/Town, Prov) RURBAN Code (City/Town, Prov)
SINGLE 08/10/1980 DATU PIANG, MAGUINDANAO 123806
Father’s Name & Citizenship Mother’s Maiden Name & Citizenship
KINADTONG MUSA - FILIPINO KADIGUIA KASIM - FILIPINO
Spouse’s name & Citizenship (if applicable) Type of Disability
N/A N/A
PART II – HIGHER EDUCATION INSTITUTION (HEI) INFORMATION
Level Name of School Bachelor’s Degr Date Graduated/ PRC Course Institution type Address/Locatio PRC School PRC Board Code
Attended ee/Pre-Medicine Completed Code n of School (City/ Code
Degree/Post- (mm/dd/yy) Town,District/Pro
Baccalaureate vince, Region)
Certificate
Bachelor’s SPA COLLEGE, BACHELOR OF 07/30/2021 2013 - - 1968 4000
Degree / Pre- INC. ELEMENTARY
Medicine Degree EDUCATION
PART III – PREVIOUS AND OTHER PRC LICENSURE EXAMINATION/S TAKEN
Name of Place of Date Taken Rating Passed Failed Conditioned Name of School Date of
Examination Examination (mm/yy) Attended Graduation
NO EXAM FOUND
1.) Examination Type (EXcode): REPEATER 2.) Number of Times Taken: 0
HAVE YOU EVER BEEN CHARGED WITH ANY ACT OR OMISSION PUNISHABLE BY LAW, RULE OR REGULATION BEFORE A FISCAL, JUDGE,
OFFICER OR ADMINISTRATIVE BODY, OR INDICTED FOR, OR ACCUSED OR CONVICTED BY ANY COURT OR TRIBUNAL OF ANY OFFENSE OR CRIME
INVOLVING MORAL TURPITUDE; NOR IS THERE ANY PENDING CASE OR CHARGE AGAINST YOU? NO
I HEREBY CERTIFY that the information and/or statements in this ACTION TAKEN BY THE APPLICATION PROCESSOR
application including the supporting documents submitted in support ISSUANCE of the FOLLOWING FORM:
thereof are all true and correct to my own knowledge, and that I am
fully aware that any false information or statement in this application or
in its attachments shall render me liable for criminal prosecution and/or
❏ NOTICE OF ADMISSION (NOA)
REMARKS _____________________________________________
administrative sanction. _______________________________________________________
PROCESSOR ________________ Date ______________________
_______________________________________________________
ACTION TAKEN BY LEGAL OFFICER (if applicable)
REMARKS _____________________________________________
LD-APP-03
Rev. 00
June 18, 2025
Page 1 of 2
LEGAL OFFICER _______________________ Date ___________
RIGHT THUMBMARK _________________________ __________________NAME & SIGNATURE______________________
Signature of Applicant ACTION TAKEN BY THE BOARD
_________________________ APPROVED DISAPPROVED CONDITIONAL
Date Accomplished
REMARKS ____________________________________________
__________________________________________________________________________
Subscribed and sworn to before me this ____________day of CHAIRMAN/ MEMBER ____________________ Date __________
_________20_____at____________. Affiant applicant exhibited ______________________NAME & SIGNATURE________________
to me his/her government-issued ID with his/her signature and ACTION TAKEN BY THE CASHIER
picture appearing thereon. AMOUNT PAID ____________ OFFICIAL RECEIPT NO. ___________
CASHIER ____________________ __________ Date __________
_________________NAME & SIGNATURE______________________
ACTION TAKEN BY THE ISSUING OFFICER
_______________________________ REMARKS ____________________________________________
PRC ADMINISTERING OFFICER __________________________________________________________________________
Administration of Oath Is Free ISSUING OFFICER _______________________ Date __________
(Office Order No. 2009-377 & 2009-379 NAME & SIGNATURE
both dated September 3, 2009)
IMPORTANT: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL MEAN NON-INCLUSION IN THE LIST OF
EXAMINEES IN THE ROOM ASSIGNMENT
LD-APP-03
Rev. 00
If you have any concerns, feedback, or suggestions, please scan the QR code.
June 18, 2025
Page 2 of 2
Powered by TCPDF (www.tcpdf.org)
