APPOINTMENT: Sep 01, 2025 (10:00 AM TO 11:00 AM) - Robinsons Ortigas (Renewal, Application for Exam, Duplicate) | REF:

EXZ98TJS9J7D | OR:
E2025-08-30412547 (08/29/2025) | AMOUNT: PHP 900.00
Professional Regulation Commission

APPLICATION FORM

Application No. Passport size colored

083235 Name of Examination _________________________________
CERTIFIED PUBLIC ACCOUNTANT
picture
with COMPLETE
X First Timer Name Tag
Date of Examination OCTOBER 24, 25 & 26, 2025
_________________________________ in plain white
Repeater
MANILA background taken
Conditioned Place of Examination _________________________________ within the last 6
Absent months
________________
08/29/2025
Date (mm/dd/yy)
PART I – PERSONAL INFORMATION

LAST NAME FIRST NAME NAME EXTENSION MIDDLE NAME

FERNANDEZ CHRISTINE JHOY N/A PRUDENTE

Maiden Name (for married female only)

N/A

Permanent Mailing Address (House No., Street, Village/Subd., Brgy., Town, Prov./City)
N/A PUROK UNO ALITAS INFANTA, QUEZON

Sex Citizenship Contact No Email Address

FEMALE FILIPINO 09091532169 fernandezcjhoy@gmail.com

Civil Status BirthDate (mm/dd/yyyy) Place of Birth (City/Town, Prov) RURBAN Code (City/Town, Prov)
SINGLE 10/30/2002 INFANTA, QUEZON 135620

Father’s Name & Citizenship Mother’s Maiden Name & Citizenship

ARTCHIE YBUT FERNANDEZ - FILIPINO MOLINA POTESTADES PRUDENTE - 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 SOUTHERN BACHELOR OF 06/14/2024 5136 ST - 0625 0100

Degree / Pre- LUZON STATE U SCIENCE IN
Medicine Degree NIVERSITY- ACCOUNTANCY
LUCBAN (SLPC)

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): COMPLETE/FIRST-TIMER 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
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