APPOINTMENT DATE: May 27, 2019 (PM) - Tandag City | OR: - | AMOUNT: PHP -

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)

REFERENCE NO:
Application No.
EXOBAOU4NPEP
-
First Timer PROFESSIONAL TEACHER
Name of Examination Secondary(Social Studies)
_________________________________
X Repeater
Conditioned Date of Examination September 29, 2019
_________________________________
Absent
Place of Examination BUTUAN CITY
_________________________________
________________
05/25/2019
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
DURIGA JERNALYN RIVAS
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
ARAS-ASAN CAGWAIT, SURIGAO DEL SUR
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
Male X Female X Filipino Others______ 09483197931 jernalyn01_duriga@yahoo.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 07/28/1990 HINATUAN, SURIGAO DEL SUR 116809
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
AVELINO RIVAS DURIGA / FILIPINO ERMELINDA RIVAS DURIGA / 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
SURIGAO DEL SUR STATE UNIVERSITY - MAIN CAMPUS TANDAG, SURIGAO DEL SUR 1047
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BS IN BUSINESS ADMINISTRATION 5096 03/28/2012 4000
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
EC4192521
________________________issued DFA BUTUAN
at _______________
REMARKS ______________________________________________
on _____________.
05/18/2015 ______________________________________________________________________________
DOCUMENTARY STAMP

CHAIRMAN/ MEMBER ______________________ Date __________

_______________________________
PRC ADMINISTERING OFFICER
Administration of Oath Is Free
(Office Order No. 2009-377 & 2009-379
both dated September 3, 2009)
____________________________________________________________
ACTION TAKEN BY THE CASHIER
AMOUNT PAID ____________
- OFFICIAL RECEIPT NO. _____________
-
PRC - CASHIER
CASHIER _________________________________ -
Date __________
____________________________________________________________
ACTION TAKEN BY THE ISSUING OFFICER
REMARKS _______________________________________________
______________________________________________________________________________
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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