Republic of the Philippines

Professional Regulation Commission Paste here

Southern Tagalog Regional Office your recent
Lucena City PASSPORT SIZE
colored picture
with full name tag
in plain white
Petition for change of registered name due to marriage background
(Please see reverse side on Requirements and Procedures)

I, _______________________________________________________________ of legal age, married, born

on_____________________________________ at _______________________________________ and a resident of
(date of birth) (place of birth)
______________________________________________________________, do hereby apply for change of name
(permanent mailing address)
from __________________________________________ to _______________________________________________
(registered name) (married name)
in the records of the Board of/for _____________________________ and the Commission.
(name of board)

I took and passed the examination given by the Board on ____________________________ and was
(month and year)
registered as ______________________ with Registration number ______________ dated _____________,
and I got married to ____________________________________ at _______________________________________
(husband’s name) (place of marriage)
on ________________________.
(date of marriage)

(A copy of Marriage Contract/Certificate of Marriage is herewith attached as Annex “A”)

I DO HEREBY CERTIFY that the foregoing date and those in the attached Marriage
Contract/Certificate of Marriage are all true and correct of my own knowledge, and that may false
declaration herein and the annex shall hold me liable for criminal/administrative prosecution.
Date Accomplished Signature (Maiden Name) Signature (Married Name)

Administering Officer

M EMetered
TERED
D O CDocumentary
UMENTARY
S Stamp
TAMP

(1) REGISTRATION DO NOT FILL THIS PORTION (2 ) RECORDS SECTION

DIVISION VERIFICATION
Registered Name Name in the Master List

Profession Examination Taken / Date / Rating

Date of Birth Date of Birth Verified by:

Registration No. Registration Date

Last Year Paid:
Assessment of Fees:
________________________
________________________
________________________
Screened by: __________________________
(3) CASH SECTION (Window 17)
(payment of fees)
(a) STATUTORY FEE:
O.R No. _______________ Date ______________
Verified by: Amount Paid ______________________________
_______________ (b) RENEWAL/DUPLICATE ID FEE
_______________ O.R No. _______________ Date ______________
_______________ Payment: _________________________________
Received by: _____________________________
 (THIS FORM IS TO BE ACCOMPLISHED AND SIGNED BY THE
PETITIONER HERSELF AND TO BE SUBMITTED IN ONE COPY)

REQUIMENTS:
1. Duly accomplished Petition Form

2. Original Marriage Certificate (issued by NSO in security paper)

3. Three (3) copies of passport size picture with complete name tag (Last Name, First Name,
Middle Name)

4. Statutory Fee of PhP225.00 and Renewal Fee, as assessed, duplicate ID Fee of PhP250.00 if ID
is still current.

5. Latest Professional License

6. Certificate of CPE (seminar attended) for applicant with expired Professional License.

PROCEDURES:
1. Submit duly accomplished Petition Form and Marriage Contract (issued by NSO in security
paper)

2. Bring the documents to Registration Division for verification of registration and assessment of
fees.

3. Proceed to Records Section for verification of examination records.

4. Proceed to the Cashier Section for payment of fees and;

5. Go back to Various Board Window – Unit B & C (Window 2); Various Board Window – Unit A
(Window 3, 4 or 5) to submit the Petition Form, Marriage Contract, Official Receipts of Payment
and pictures.

PRC-Luc/mrgg/rvc/bem/rfm/arg/01.22.2010