LET Application Form

PRC Form No. 001
(Revised September 2010)

NOT FOR SALE

Republic of the Philippines

REPRODUCTION
IS ALLOWED

PROFESSIONAL REGULATION COMMISSION

Application No.

Manila
PRC Central Office : APPLICATION DIVISION P. Paredes St., Sampaloc 1008 Manila, Philippines
Website : www.prc.gov.ph Tel. No.: (63-2) - 314-00-27

Paste here your recent passport size picture with COMPLETE
Name Tag in plain white background APPLICATION FORM

First Timer
Repeater
Conditioned
Absent

Name of Examination
Date of Examination
Place of Examination

Date (mm/dd/yy)

Scanned/Photocopied picture not accepted

NOTICE : This application must be filled out in INK and in the applicant’s handwriting. All supporting documents shall become part of the records of the Commiss ion. All applic ations must be f iled PERSONALLY by the applicant.

PART I -PERSONAL INFORMATION
MIDDLE NAME

GIVEN NAME/S

SURNAME
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
Gender

Male

Civil Status
Single

Contact Numbers (Landline & Mobile)

Citizenship

Female

Filipino

(Town/City, Prov)

E-mail Address

__ __ __ __
Others __ __ __ __
RURBAN Code (Town/City, Prov)

Place of Birth (City/Town,Prov.)

Date of Birth (mm/dd/yy)
Married

RURBAN Code

Zip Code

Widow/er
Father’s Name & Citizenship

Spouse’s Name & Citizenship

Mother’s Name & Citizenship

HAVE YOU EVER BEEN CHARGED AND CONVICTED BY FINAL JUDGEMENT BY ANY COURT OF JUSTICE/MILITARY TRIBUNAL OR
ADMINISTRATIVE BODY?
No
Yes
(If yes, attach hereto a copy of the decision)

PART II -EDUCATIONAL INFORMATION
PRC School Code

Address/Location of School

Name of School
Degree/Course Obtained

Other Higher Educational Attainment

PRC Board Code

Date Graduated (mm/dd/yy)

PRC COURSE Code

Date Graduated

Address/Location of School

Name of School

(mm/dd/yy)

PRC