APPOINTMENT DATE: Jun 20, 2022 (10:00 AM TO 11:00 AM) - Robinsons Place Pangasinan

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)

REFERENCE NO: EX5GLX1R4FTA
Application No.
OR: E2022-06-01818153 | AMOUNT: PHP 900.00
-
First Timer PROFESSIONAL TEACHER
Name of Examination Elementary
_________________________________
X Repeater
Conditioned Date of Examination SEPTEMBER 25, 2022
_________________________________
Absent
Place of Examination Rosales, Pangasinan
_________________________________
________________
06/07/2022
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
AQUINO CAMILA DUQUE
Maiden Surname (for married female only)
DOQUE
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
020 STREET 2 GENERAL LUNA MANGATAREM, PANGASINAN
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
Male X Female X Filipino Others______ 09103859014 camilaaquino496@gmail.com
Civil Status Date of Birth(mm/dd/yy) Place of Birth (City/Town,Prov) RURBAN Code(Town/City,Prov)
Single X Married Widow/er 07/30/1997 MANGATAREM, PANGASINAN 015527
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
ARNEL F.AQUINO / FILIPINO CAMILO DUQUE / FILIPINO NARCISA DUQUE / 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
MYSTICAL ROSE COLLEGE OF SCIENCE & TECHNOLOGY POGON LOMBOY, MANGATAREM, PANGASINAN 1969
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BACHELOR OF ELEMENTARY EDUCATION 2013 04/02/2018 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
052534912242
________________________issued MANGATAREM PANGASINAN
at _______________
REMARKS ______________________________________________
on _____________.
06/08/2019 ______________________________________________________________________________
DOCUMENTARY STAMP

CHAIRMAN/ MEMBER ______________________ Date __________

____________________________________________________________
ACTION TAKEN BY THE CASHIER
_______________________________
PRC ADMINISTERING OFFICER AMOUNT PAID ____________
900.00 OFFICIAL RECEIPT NO.E2022-06-01818153
_____________
Paymaya - Gcash Payment
CASHIER _________________________________ 06/07/2022
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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