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PRC APP Form No. 001 (Rev. Sept. 2004)

Professional Mechanical Engineer

_________________________
NAME OF EXAMINATION

Paste here
_________________________ your recent
Date of Examination
1½x1½
Republic of the Philippines Colored picture with
Riyadh, Saudi Arabia
_________________________ Professional Regulation Commission Complete name tag
Place of Examination In plain white
Manila background
✔ First Timer
Repeater APPLICATION DIVISION
Conditional/Removal
(Subjects to be taken)
_________________________
_________________________
ACTION SHEET
ACTION SHEET DATE OF FILING: _______________
_________________________ PERRC No. ____________________

LAST NAME FIRST NAME MIDDLE NAME

AGUADO, LEONARDO BERNABE
MAILING ADDRESS
5597 Maya St., Sulok, Bo. Ugong, Valenzuela City, Philippines
DATE OF BIRTH PLACE OF BIRTH CELL PHONE/TEL. NO.
(mm/dd/yy) 0 8 0 9 6 9 Quezon City 00966542029384
NAME/LOCATION OF SCHOOL DATE OF GRADUATION
Technological Institute of the Philippines / Manila, Philippines (mm/yy) 0 4 9 1

PREVIOUS PRC EXAMINATION(S) TAKEN

DATE TAKEN RESULT OF EXAMINATION (Pls. Check) VERIFIED (Records Section)
NAME OF EXAMINATION RATING
(mm/yy) Passed Failed Conditioned (Full Signature)
Mechanical Engineer 10 / 91 71% ✔

__________________________
Applicant's Signature
DO NOT FILL UP BELOW THIS LINE

1. ACTION TAKEN BY THE PROCESSOR

Checklist of Requirements
Original and photocopy of Transcript of Records w/ scanned Record of Deliveries Handled (Midwife)

Picture, remarks “FOR BOARD EXAM PURPOSES “,

NBI Clearance (Arch/CPA/Crim/Chem Eng/ Vet med)
Special Order and Date of Graduation,Course & Degree
Original and photocopy of Birth Certificate (NSO) Summary of Related Learning Experience (Nurse)
Original and photocopy of Marriage Contract (NSO) Record of OR-DR Cases (Nurse)

(for married female only)

Certificate of 1,000 Cases Hours (Social Worker)
Certification of Good Moral Character (Agri, Crim., Certification of Mine and Mill Practice (Mining Engr.)
Fish. Tech., Forester, Librarian, Environmental Planner)
Four (4) 1 ½ x 1 ½ colored pictures with full name tag Board Certificate/PRC License (Ocular Pharm, Nurse-Midwife)
Community Tax Certificate (cedula) Certificate of Special Pharmacology Course
Any valid identification card OTHERS ____________________________________
Refresher Course (CPA, Med. Tech., PT, OT, Physician, Pharm, Optometry) ____________________________________
Copy of College Thesis – Approval & Title Page (Chemist)
Certificate of Experience (RME, CPM, Master Plumber, Env'tal Planner, Landscape Arch. )
Affidavit of Competency (PME, CPM) Issuance of the following forms
Certificate of Employment (RME, CPM, Master Plumber, Env Plnr) Computerized Application Form (CAF)
Detailed Description of Equipment (CPM) Notice of Admission (NOA)

Diploma, Logbook/Mentor's Prof. License , PTR & IAPOA (Architect)

Permanent Examination & Registration Record Card
Daily Time Record (Pharmacist) (PERRC)
Certificate of Internship (Physician, Pharm, PT, OT)

Remarks: _______________________________________________________________________________________
PROCESSOR _________________________________________ DATE ____________________________________
(Full Signature)
2. ACTION TAKEN BY THE LEGAL DIVISION (as applicable)
Remarks: ______________________________________________________________________________________

LEGAL OFFICER ______________________________________ DATE ___________________________________

3. ACTION TAKEN BY THE BOARD

APPROVED DISAPPROVED CONDITIONAL

Remarks: ______________________________________________________________________________________

CHARIMAN / MEMBER _________________________________ DATE ___________________________________

4. ACTION TAKEN BY THE CASHIER

AMOUNT _______________________________ OFFICIAL RECEIPT No. __________________________________

RECEIPT ISSUED BY ___________________________________ DATE ___________________________________

5. ACTION TAKEN BY THE ISSUING OFFICER

Remarks ______________________________________________________________________________________
ISSUING OFFICER ____________________________________ DATE ___________________________________
(Full Signature)
6. NOTICE OF ADMISSION, PROGRAM OF EXAMINATION and EXAMINEE'S GUIDE received by _________________