Republic of the Philippines Professional Regulation Commission Lucena City APPLICATION STUB (This also serves as your Notice of Admission)

Republic of the Philippines Professional Regulation Commission Lucena City TEACHERS APPLICATION FORM (TAF) ELEMENTARY CONTENT CORSES SPECIAL EDUCAION Part I PERSONAL INFORMATION LAST NAMEFIRST NAMEMIDDLE NAME COMPLETE MAILING ADDRESS (House No. Street, Town/City, Province) ZIP CODEPRC RURBAN CODE (Town/City/Province) Gender MALEFEMALE CITIZENSHIPE-MAILCONTACT NUMBER (LANDLINE & MOBILE)

Civil Status SINGLEMARRIEDWIDOW/ER DATE OF BIRTH (mm/dd/yyyy) ___/___/_____ PLACE OF BIRTH (Town/City, Province) SPOUSE NAME CITIZENSHIPFATHERS NAME CITIZENSHIPMOTHERS NAME CITIZENSHIP HAVE YOU EVER BEEN CONVICTED IN A FINAL J UDGMENT BY ANY COURT, MILITARY TRIBUNAL OR ADMINISTRATIVE BODY? YES NO(If yes, attach hereto a copy of the decision) Part II EDUCATIONAL INFORMATION COURSE COMPLETED MAJ OR FIELD OF STUDY COURSE CODE DATE GRADUATED (mm/yyyy) NAME OF SCHOOLLOCATION BACHELORS DEGREE _ _ /_ _ _ _ For EquivalentN O N- B E E d Graduates No. of units in Prof. Education ____________ GRADUATE DEGREE Part III PREVIOUS LICENSURE EXAMINATION FOR TEACHERS TAKEN LAST EXAMINATION TAKEN MONTH AND YEAR (mm/yyyy)PLACE OF EXAMINATION _ _ /_ _ _ _

ManilaLucena Others: ___________________ I HEREBY CERTI FY that the information and/or statements in this application including the exhibits submitted in support thereof are all true and correctofmyownknowledge,andthatIamfullyawarethatanyfalse information or statement in this application or in its attachments shall render me liable for criminal prosecution and / or administrative sanction. IAMWILLINGTOBESUBJ ECTEDTOAVALIDATINGEXAMINATION IN CASE THE TEST RESULT IN MY PLACEOF EXAMINATION ARE STATISTICALLY IMPROBABLE. ACTION TAKEN BY THE APPLICATION PROCESSOR Remarks: ____________________________________ _______________________________________________ Processed by: _______________________________ Date: _______________________________________________ ACTION TAKEN BY THE BOARD APPROVED DISAPPROVED Remarks: _____________________________________ ________________________________________________ Chairman: ___________________Date___________ Member: ___________________Date___________ _________________________________ Signature of Applicant ______________________________ Date Accomplished ACTION TAKEN BY THE CASH SECTION Amount: ______________________________________ O.R. No: ______________________________________ Date: _________________________________________ Issued by: ____________________________________ ACTION TAKEN BY THE ISSUING OFFICER Remarks: _____________________________________ ________________________________________________ Issued by: ____________________________________ Date: ________________________________________________ SUBSCRIBEDandSWORNtobeforemethis____dayof_ _______ _ ________20____at__________________________.Affiantapplicant exhibited to me his/her Community Tax Certificate No. __________________ issued at _________________________ on ___________________________. ________________________ PRC Administering Officer Administration of Oath is FREE (Office Order No. 2009-377 & 2009-379 both dated September 3, 2009 FOR BEST RESULT, PRINT THIS APPLICATION FORM USING INK/LASER JET AND 8.5 X 14 PAPER. REPRODUCTION ISALLOWED PRC OPT Form No. 101-2 (Rev. 04-2011) 1ST TIMER [NEW] REPEATER ABSENT APPLICATION NO ___________________ PASTE HEREPASSPORT SIZE PHOTO with COMPLETE Name Tag in plain white background (taken within 3 months) Scanned/Photocopied picture not acceptable RIGHT THUMBMARK Documentary Stamp PASTE HEREPASSPORT SIZE PHOTO with COMPLETE Name Tag in plain white background (Taken within 3 months) Scanned/Photocopied Picture not acceptable Application No ________________ Mr./Ms. ____________________________________________________________________ ThisistoinformyouthatyourapplicationfortheTeacherLicensure Examinationtobegivenon______ __________ _______ _______ hasbeen CONDITIONALLYAPPROVEDPENDINGFINALREVIEWAND VERIFICATION of your credentials. Very truly yours, _________________________ PRC Issuing Officer / DateMAJOR: ________________________ (FOR PRC USE ONLY) ACKNOWLEDGMENT ON THE RECEIPT OF TEST BOOKLETS & ANSWER SHEETS Iacknowledgereceiptofthetestbooklets&answer sheetsoftheabove-namedexamineeonthesubjects indicated below: Room Watchers SignatureDate General Ed Professional Ed Major FAILURE TO SUBMIT THE EVALUATED APPLICATION FORM TO THE ISSUING OFFICER WILL EXCLUDE THE APPLICANT FROM THE LIST OF EXAMINEES AND FORFEITURE OF THE AMOUNT PAID. NOTE: GET/ COPY YOUR APPLCIATION NUMBER FROM THE LIST OF EXAMINEES WITH THE ROOM WATCHERS ON EXAM DAY. ELEMENTARY SECONDARY WARNING: This application must be filled out personally by the applicant. All documents submitted shall form part of the records of this Commission and are subject to verification. Any false statement or misrepresentation made in this application is a ground for disqualification and criminal prosecution/administrative sanction for PRC Lucena ATE/RVC/ARGagalac REQUIREMENTS Original and photocopy ofBirth Certificate issued by the National Statistics Office (NSO) in security paper Original and photocopy ofMarriage Certificate issued by the NSO in security paper (for married female applicants) For NON-AVAILABILITY OF RECORDS Negative Certification issued by NSO and Certificate of Live Birth/Marriage from the Local Civil Registrar (LCR) duly authenticated by authorized NSO Statistician. ForNON-READABLEentriesinNSOBirth/ MarriageCertificateAclearcopyofLCRForm102orForm1Aduly signed/certified by the Local Civil Registrar FOREDUCATIONGRADUATES:OriginalandphotocopyoftheTranscriptofRecordsfordegreeearnedwithSCANNED PICTURE, remarks FOR BOARD EXAMINATION PURPOSES ONLY, bearing the exact date of graduation and Special Order Number FORNON-EDUCATIONGRADUATES:OriginalandphotocopyoftheTranscriptofRecordsfordegreeearnedwith SCANNEDPICTURE,remarksFORBOARDEXAMINATI ONPURPOSESONLY,bearingtheexactdateofgraduationand Special Order Number indicated thereon and Transcript of Records for 18 units of credit in Professional Education courses Original and photocopy of College Diploma if exact date of graduation is not indicated on the Transcript of Records CHED recognition or permit to operate for graduates of new schools/programs OriginalandphotocopyofMarriageCertificateissuedbytheNationalStatisticsOfficeinsecuritypaper(formarriedfemale applicants) Three(3)recentidenticalcopiesofpassportsizepicturesinplainwhitebackgroundwithcompletenametag(lastname,first name, middle name) One (1) piece window envelope with metered mailing stamp for ordinary mail (for Report of Rating) Examination fee of PhP900.00 Current Community Tax Certificate (Cedula) INSTRUCTION IN APPLYING FOR EXAMINATION 1.Apply on-line through the OnLine Application System (OAS) @ http://www.prc.gov.ph/online/application. For walk-in applicants: Proceed to OAS Kiosk, (Counters A, B, C) encode data and save record. 2.Submit picture at Counter 1 for scanning. 3.Proceed to Counter 11 or 12 and submit complete basic requirements for evaluation and processing. 4.Pay exam fee to Cashier at Counter 17 and wait for the issuance of Official Receipt (OR). 5.Pay documentary stamp/mailing envelop at the Photo Booth (in front of Window 17) 6.Submit all documents to Issuing Officer at Counter 2 or 9 for final evaluation and issuance of notice of admission (NOA). 7.Keep NOA & verify school assignment one week before exam at PRC Lucena website, www.prclucena.weebly.com. S T A T U SC O D E S 1.EX CODE - Examination Type Code Print 1 for Complete/First Timer Print 2 for Repeaters Print 3 for Removal/Conditioned 2.NX CODE - Number of Times Taken Print 0 for None Print 1 for Once Print 2 for Twice and so on IMPORTANT 1.Keepthisstubwithyou.ApplicationNumberwillbeusedwhenyoufilluptheIdentificationSheetonthedayofexamination (present this stub when you verify your test results/apply for registration). 2.Your Notice of Room Assignment will be mailed to you. Ifyou failedto receive your Notice of Room Assignment, please verify from the PRC Lucena blog site www.prclucena.weebly.com two to three days before the examination day.3.Bring pencils (No. 1 or 2), ball pen (with black ink only), one piece (1) long brown envelope, one long white transparent plastic envelope, this stub and Official Receipt with you in the examination room. 4.Report to your school assignment before 6:00 a. m. on examination day. Late examinees will not be admitted. Failure to come on your scheduled examination will mean forfeiture of examination fee.