TO BE ACCOMPLISHED

PERSONALLY BY THE
PROFESSIONAL

PRC REG Form No. 003 (Rev. 01/2006)

Republic of the Philippines

Professional Regulation Commission

RENEWAL
DUPLICATE
REPRINT
CHANGE OF NAME
CHANGE OF DATE OF BIRTH
PLS. PRINT LEGIBLY

Lucena City

Paste here
your recent
PASSPORT SIZE
colored picture with
complete name tag in
plain white background

REGISTRATION DIVISION
APPLICATION FOR PROFESSIONAL IDENTIFICATION CARD

Last Name
PERMANENT MAILING ADDDRESS:
DATE FILED:
REGISTRATION DATE:

First Name

Middle Name

PROFESSION:
LICENSE / REGISTRATION NO:

EXAM DATE:
EXPIRATION DATE:

(mm/dd/yyyy)

CITIZENSHIP:

BIRTH DATE:

CONTACT NO:
(mm/dd/yyyy)

This is to certify that the above information are true and correct
Signature of Licensee
FOR PRC PROCESSING

YLP FROM:

TO:
P
SURCHARGE:
TOTAL AMOUNT:
VERIFIED AND ASSESSED BY:

AMOUNT:

O.R. NO.:

DATE:

ISSUED BY:

PRC-LUCENA CLAIM SLIP (to be filled up by the applicant)

ISSUED BY: __________________________________________
NAME:

DATE OF BIRTH:

DATE FILED:
_________________________
AMOUNT:

PROFESSION:
REGISTRATION NO.:

OR NO.:
REGISTRATION DATE:

APPLICATION TYPE: RENEWAL DUPLICATE

REPRINT

DATE PAID:
CHANGE OF STATUS

CORRECTION OF DATE OF BIRTH/NAME

Please present this slip to claim your professional ID on _________________________ at Window _______.

(NOTE: AUTHORIZED REPRESENTATIVE WHO IS NON-PRC LICENSE HOLDER SHOULD PRESENT SPECIAL POWER OF ATTORNEY FROM
THE REGISTERED PROFESSIONAL AND THIS ORIGINAL CLAIM SLIP. AUTHORIZED REPRESENTATIVE WHO HOLDS A VALID PRC ID SHALL
ONLY PRESENT AUTHORIZATION LETTER AND THIS ORIGINAL CLAIM SLIP).
(042) 373-7316

PROCEDURES

Step 1
Step 2
Step 3
Step 4

Present duly accomplished form together with the requirements at the designated window
for assessment.
Pay prescribed fee at the Cashier (Window 17)
Submit this form and get your claim slip at the following profession counters:
Window 2 - UNIT C; Window 3 - UNIT B;
Window 7 - UNIT A
Claim your professional license as scheduled. Please refer to your claim slip for further
instruction.

REQUIREMENTS

1. Duly accomplished form.

2. Two (2) pcs passport sized picture: close up, colored, plain white background with complete
name tag (last name, first name, middle name).
3. Recent professional ID card.
4. In case of LOST professional ID card which is still current, the applicant shall submit notarized
Affidavit of Loss.
5. In case of DESTROYED professional ID card, the applicant shall surrender the destroyed card.

NOTE: As the authorized representative. I assume direct and full

responsibility/liability for the security of the professional ID.

____________________________________________________
Signature over Printed Name of Representative/Profession/License No.