APPOINTMENT DATE: Jun 19, 2024 (01:00 PM TO 02:00 PM) - PRC Cebu - Robinsons (Exam Application only)
Professional Regulation Commission
APPLICATION FORM
NOT FOR SALE (REPRODUCTION IS ALLOWED)
REFERENCE NO: EXMSPUIMAJVY
OR: E2024-06-08615385 | AMOUNT: PHP 900.00
Application No.
027229
X First Timer
Repeater
Conditioned
Absent
06/14/2024
Date(mm/dd/yy)
Name of Examination
PSYCHOMETRICIAN
Date of Examination
AUGUST 11 - 12, 2024
Place of Examination
Cebu
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
BARDENAS
JISELLE
Maiden Surname (for married female only)
MIDDLE NAME
DUMAGUIT
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
56 F. PACAñA STREET TISA CEBU CITY
Gender
Citizenship
Contact numbers (Landline & Mobile)
X Filipino
Male
X Female
Others
09321389551
E-mail Address
jiszellebardenas@gmail.com
Civil Status
X Single
RURBAN Code(Town/City,Prov)
083719
Married
Widow/er
Spouse’s name & Citizenship
Date of Birth(mm/dd/yy)
04/05/2001
Place of Birth (City/Town,Prov)
HILONGOS, LEYTE
Father’s Name & Citizenship
WILFREDO N. BARDENAS / FILIPINO
Mother’s Name & Citizenship
REBECCA D. BARDENAS / 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
CEBU NORMAL UNIVERSITY (CEBU STATE COLLEGE)
Degree/Course Obtained
BS IN PSYCHOLOGY
Other Higher Educational Attainment
Name of School
Address/Location of School
PRC School code
OSMENA BOULEVARD, CEBU CITY, CEBU
0778
PRC COURSE Code
Date Graduated (mm/dd/yy)
PRC Board Code
1101
06/07/2023
4530
PRC SCHOOL
Date
Graduated
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
Result of Examination (pls check)
Passed
Failed
Cond.
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.
Exam No.
Others (specify name)
2.) Number of Times Taken
Verified by
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
DOCUMENTARY STAMP
Subscribed and sworn to before me this
day of
20
at
. Affiant applicant exhibited
to me his / her Community Tax Certificate No.
4952-9631-7821-5791
CEBU CITY
issued at
on 10/07/2022 .
Date
ACTION TAKEN BY THE BOARD
APPROVED
DISAPPROVED
CONDITIONAL
REMARKS
CHAIRMAN/ MEMBER
Date
ACTION TAKEN BY THE CASHIER
PRC ADMINISTERING OFFICER
AMOUNT PAID
900.00
OFFICIAL RECEIPT NOE. 2024-06-08615385
CASHIER Paymaya - _G c ash Payment
Administration of Oath Is Free
(Office Order No. 2009-377 & 2009-379
both dated September 3, 2009)
Date
06/14/2024
ACTION TAKEN BY THE ISSUING OFFICER
REMARKS
ISSUING OFFICER
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
Date
APP-01
Rev. 00
February 25, 2015
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