APPOINTMENT DATE: Jan 30, 2023 (08:00 AM TO 09:00 AM) - Digos City
Professional Regulation Commission
APPLICATION FORM
NOT FOR SALE (REPRODUCTION IS ALLOWED)
REFERENCE NO: EX5AGCSY77F2
OR: E2023-01-03726598 | AMOUNT: PHP 900.00
Application No.
457062
Name of Examination
PROFESSIONAL TEACHER
Secondary(Mathematics)
_________________________________
Date of Examination
MARCH 19, 2023
_________________________________
Place of Examination
Davao
_________________________________
X First Timer
Repeater
Conditioned
Absent
01/20/2023
________________
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
MONTALBO
ROGIELYN
Maiden Surname (for married female only)
MIDDLE NAME
MILA
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
PUROK 7 RELOCATION TAGANSULE DAVAO CITY, DAVAO DEL SUR
Gender
Citizenship
Contact numbers (Landline & Mobile)
X Female
X Filipino
Male
Others______
09367275808
E-mail Address
rogielynmilamontalbo29@gmail.com
Civil Status
X Single
RURBAN Code(Town/City,Prov)
112402
Married
Spouse’s name & Citizenship
Widow/er
Date of Birth(mm/dd/yy)
04/27/1998
Place of Birth (City/Town,Prov)
DAVAO CITY, DAVAO DEL SUR
Father’s Name & Citizenship
FLORITO PEPITO MONTALBO / FILIPINO
Mother’s Name & Citizenship
MARICRIS MILA MONTALBO / 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
DAVAO DEL SUR STATE COLLEGE(FOR SPAMAST-MATI-DIGOS CITY
MATI, DIGOS CITY, DAVAO DEL SUR
1960
Degree/Course Obtained
PRC COURSE Code
Date Graduated (mm/dd/yy)
PRC Board Code
BACHELOR OF SECONDARY EDUCATION
2017
07/07/2022
4000
PRC SCHOOL
Date Graduated
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)
Name of Examination
Place of
Examination
Date Taken
(mm/yy)
Rating
Review School/Center:
Self-Review
School-Based Review
STATUS CODES (refer at the back)
1.) Examination Type (EXcode)
I HEREBY CERTIFY that the information and/or
statements in this application including the supporting
documents submitted in support thereof are all true and
correct to my own knowledge, and that I am fully aware that
any false information or statement in this application or in its
attachments shall render me liable for criminal prosecution
and/or administrative sanction.
Result of Examination (pls check)
Passed
Failed
Cond.
Exam No.
Verified by
Others (specify name) __________________________
2.) Number of Times Taken 0
ACTION TAKEN BY THE APPLICATION PROCESSOR
ISSUANCE of the FOLOWING FORMS
NOTICE OF ADMISSION
PERMANENT EXAMINATION &
(NOA)
REGISTRATION RECORD CARD (PERRC)
REMARKS ______________________________________________
______________________________________________________________________________
PROCESSOR_____________________________ Date ___________
RIGHT THUMBMARK
_______________________
Signature of Applicant
_______________________
Date Accomplished
____________________________________________________________
ACTION TAKEN BY LEGAL OFFICER (if applicable)
REMARKS ______________________________________________
______________________________________________________________________________
LEGAL OFFICER __________________________ Date ___________
DOCUMENTARY STAMP
Subscribed and sworn to before me this __________day of
_________20____at__________. Affiant applicant exhibited
to me his / her Community Tax Certificate No.
1213006827290
DIGOS CITY
________________________issued
at _______________
09/07/2022
on _____________.
____________________________________________________________
ACTION TAKEN BY THE BOARD
APPROVED
DISAPPROVED
CONDITIONAL
REMARKS ______________________________________________
______________________________________________________________________________
CHAIRMAN/ MEMBER ______________________ Date __________
____________________________________________________________
_______________________________
PRC ADMINISTERING OFFICER
ACTION TAKEN BY THE CASHIER
AMOUNT PAID ____________
OFFICIAL RECEIPT NO.E2023-01-03726598
_____________
900.00
Paymaya - Gcash Payment
01/20/2023
CASHIER _________________________________
Date __________
____________________________________________________________
Administration of Oath Is Free
(Office Order No. 2009-377 & 2009-379
both dated September 3, 2009)
ACTION TAKEN BY THE ISSUING OFFICER
REMARKS _______________________________________________
______________________________________________________________________________
ISSUING OFFICER ________________________ Date __________
IMPORTANT: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL MEAN
NON-INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF EXAMINATION FEES
APP-01
Rev. 00
February 25, 2015
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