APPOINTMENT DATE: Jun 18, 2024 (09:00 AM TO 10:00 AM) - Robinsons Place Manila (Renewal, Application for Exam, Duplicate)
Professional Regulation Commission
APPLICATION FORM
NOT FOR SALE (REPRODUCTION IS ALLOWED)
REFERENCE NO: EXR7TS3VHV42
OR: E2024-06-08602207 | AMOUNT: PHP 900.00
Application No.
035228
X First Timer
Repeater
Conditioned
Absent
06/13/2024
________________
Name of Examination
REGISTERED
ELECTRICAL ENGINEER
_________________________________
Date of Examination
AUGUST 24 - 25, 2024
_________________________________
Place of Examination
Manila
_________________________________
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
GONZALES
ZAIRUS
Maiden Surname (for married female only)
MIDDLE NAME
ABIOG
Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
160 QUILITISAN QUILITISAN CALATAGAN, BATANGAS
Gender
Citizenship
Contact numbers (Landline & Mobile)
X Male
X Filipino
Female
Others______
09558957037
E-mail Address
zairus.gonzales@gmail.com
Civil Status
X Single
RURBAN Code(Town/City,Prov)
131013
Married
Spouse’s name & Citizenship
Widow/er
Date of Birth(mm/dd/yy)
02/03/2000
Place of Birth (City/Town,Prov)
LIAN, BATANGAS
Father’s Name & Citizenship
GERARDO V. GONZALES / FILIPINO
Mother’s Name & Citizenship
ARLYN A. GONZALES / 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
CAVITE STATE UNIVERSITY (DON SEVERINO AGR'L. COLL.)
INDANG, CAVITE
0011
Degree/Course Obtained
PRC COURSE Code
Date Graduated (mm/dd/yy)
PRC Board Code
BS IN ELECTRICAL ENGINEERING
3047
02/29/2024
1100
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
(NOA)
PERMANENT EXAMINATION &
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
ACTION TAKEN BY THE BOARD
_________20____at__________. Affiant applicant exhibited
APPROVED
DISAPPROVED
CONDITIONAL
to me his / her Community Tax Certificate No.
6516-0813-5290-4784
MARTIRES CITY
________________________issued
atTRECE
_______________
REMARKS ______________________________________________
03/06/2023
on _____________.
______________________________________________________________________________
CHAIRMAN/ MEMBER ______________________ Date __________
____________________________________________________________
_______________________________
PRC ADMINISTERING OFFICER
ACTION TAKEN BY THE CASHIER
AMOUNT PAID ____________
OFFICIAL RECEIPT NO.E2024-06-08602207
_____________
900.00
Paymaya - Gcash Payment
06/13/2024
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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