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Application Form PRC LET

This document is an application form for the Professional Regulation Commission teacher licensure examination. It contains personal information about the applicant such as name, address, educational background, and examination history. The form shows that Marlou Noya is applying to take the Secondary MAPEH teacher licensure exam on March 29, 2020 in Cagayan de Oro. It lists his degree in Physical Education from Bukidnon State University and confirms he has not previously failed or been convicted of any offenses. The processed form indicates his application has been approved.

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Marlou
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
455 views

Application Form PRC LET

This document is an application form for the Professional Regulation Commission teacher licensure examination. It contains personal information about the applicant such as name, address, educational background, and examination history. The form shows that Marlou Noya is applying to take the Secondary MAPEH teacher licensure exam on March 29, 2020 in Cagayan de Oro. It lists his degree in Physical Education from Bukidnon State University and confirms he has not previously failed or been convicted of any offenses. The processed form indicates his application has been approved.

Uploaded by

Marlou
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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APPOINTMENT DATE: Jan 28, 2020 (04:00 PM TO 05:00 PM) - PRC Cagayan de Oro

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)


REFERENCE NO: EXMP1YZNWHT6
Application No.
OR: - | AMOUNT: PHP -
-
X First Timer PROFESSIONAL TEACHER
Repeater Name of Examination Secondary(MAPEH)
_________________________________
Conditioned Date of Examination March 29, 2020
_________________________________
Absent
Place of Examination Cagayan de Oro
_________________________________
________________
01/17/2020
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
NOYA MARLOU SOLITO
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
P-5, LAGUITAS MALAYBALAY, BUKIDNON
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
X Male Female X Filipino Others______ 09367411956 [email protected]
Civil Status Date of Birth(mm/dd/yy) Place of Birth (City/Town,Prov) RURBAN Code(Town/City,Prov)
X Single Married Widow/er 05/26/1998 MALAYBALAY, BUKIDNON 101312
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
FEDERICO NOYA / FILIPINO LORNA NOYA / 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
BUKIDNON STATE UNIVERSITY(FOR.BUKIDNON STATE COLLEGE)-MAIN
MALAYBALAY,
CAMPUS BUKIDNON 0818
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BACHELOR IN PHYSICAL EDUCATION 2167 04/07/2019 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
F-932
________________________issued BUKIDNON STATE UNIVERSITY
at _______________
REMARKS ______________________________________________
on _____________.
09/23/2019 ______________________________________________________________________________
DOCUMENTARY STAMP

CHAIRMAN/ MEMBER ______________________ Date __________


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