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The document is an application form for the Civil Engineer licensure examination scheduled for April 28 & 29, 2025, with an appointment date of February 5, 2025. The applicant, Krizza Lyn Bansale Fernandez, is a first-time examinee from Valenzuela, Metro Manila, and has paid a fee of PHP 900.00 for the examination process, which includes personal and educational information, as well as a certification of the truthfulness of the provided information.

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Kenma Kozume
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2 views

Doc

The document is an application form for the Civil Engineer licensure examination scheduled for April 28 & 29, 2025, with an appointment date of February 5, 2025. The applicant, Krizza Lyn Bansale Fernandez, is a first-time examinee from Valenzuela, Metro Manila, and has paid a fee of PHP 900.00 for the examination process, which includes personal and educational information, as well as a certification of the truthfulness of the provided information.

Uploaded by

Kenma Kozume
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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APPOINTMENT DATE: Feb 05, 2025 (10:00 AM TO 11:00 AM) - Lucky Chinatown

Professional Regulation Commission

APPLICATION FORM

NOT FOR SALE (REPRODUCTION IS ALLOWED)


REFERENCE NO: EXOIMRUDBEGG
Application No.
OR: E2025-01-10643647 | AMOUNT: PHP 900.00
135298
X First Timer
Repeater Name of Examination CIVIL ENGINEER
_________________________________
Conditioned Date of Examination APRIL 28 & 29, 2025
_________________________________
Absent
Place of Examination Manila
_________________________________
________________
01/18/2025
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 MIDDLE NAME
FERNANDEZ KRIZZA LYN BANSALE
Maiden Surname (for married female only)

Permanent Mailing Address (House no., Street, Village/Subd., Brgy., Town, Prov./City)
185 F. BAUTISTA MARULAS VALENZUELA, METRO MANILA
Gender Citizenship Contact numbers (Landline & Mobile) E-mail Address
Male X Female X Filipino Others______ 09162201390 [email protected]
Civil Status Date of Birth(mm/dd/yy) Place of Birth (City/Town,Prov) RURBAN Code(Town/City,Prov)
X Single Married Widow/er 11/23/2000 VALENZUELA, METRO MANILA 047504
Spouse’s name & Citizenship Father’s Name & Citizenship Mother’s Name & Citizenship
TIRSO FERNANDEZ / FILIPINO MELANIE FERNANDEZ / 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
PAMANTASAN NG LUNGSOD NG VALENZUELA POB. II, MALINTA, VALENZUELA, MM 1944
Degree/Course Obtained PRC COURSE Code Date Graduated (mm/dd/yy) PRC Board Code
BACHELOR OF SCIENCE IN CIVIL ENGINEERING 3044 07/05/2023 0600
Date Graduated PRC SCHOOL
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)
Place of Date Taken Result of Examination (pls check)
Name of Examination Rating Exam No. Verified by
Examination (mm/yy) Passed Failed Cond.

Review School/Center: Self-Review School-Based Review Others (specify name) __________________________


STATUS CODES (refer at the back) 1.) Examination Type (EXcode) 2.) Number of Times Taken 0

I HEREBY CERTIFY that the information and/or ACTION TAKEN BY THE APPLICATION PROCESSOR
statements in this application including the supporting ISSUANCE of the FOLOWING FORMS
documents submitted in support thereof are all true and
correct to my own knowledge, and that I am fully aware that NOTICE OF ADMISSION PERMANENT EXAMINATION &
(NOA) REGISTRATION RECORD CARD (PERRC)
any false information or statement in this application or in its
attachments shall render me liable for criminal prosecution REMARKS ______________________________________________
and/or administrative sanction. ______________________________________________________________________________

PROCESSOR_____________________________ Date ___________


RIGHT THUMBMARK _______________________ ____________________________________________________________
Signature of Applicant ACTION TAKEN BY LEGAL OFFICER (if applicable)
_______________________ REMARKS ______________________________________________
Date Accomplished ______________________________________________________________________________

LEGAL OFFICER __________________________ Date ___________


Subscribed and sworn to before me this __________day of ____________________________________________________________
_________20____at__________. Affiant applicant exhibited ACTION TAKEN BY THE BOARD
to me his / her Community Tax Certificate No. APPROVED DISAPPROVED CONDITIONAL
2158-6283-4057-8025
________________________issued at VALENZUELA CITY
_______________
REMARKS ______________________________________________
on _____________.
07/05/2022 ______________________________________________________________________________
DOCUMENTARY STAMP

CHAIRMAN/ MEMBER ______________________ Date __________


____________________________________________________________
ACTION TAKEN BY THE CASHIER
_______________________________
PRC ADMINISTERING OFFICER AMOUNT PAID ____________
900.00 OFFICIAL RECEIPT NO.E2025-01-10643647
_____________
Paymaya - Gcash Payment
CASHIER _________________________________ 01/18/2025
Date __________
____________________________________________________________
ACTION TAKEN BY THE ISSUING OFFICER
Administration of Oath Is Free REMARKS _______________________________________________
(Office Order No. 2009-377 & 2009-379 ______________________________________________________________________________
both dated September 3, 2009)
ISSUING OFFICER ________________________ Date __________

IMPORTANT: FAILURE TO SUBMIT THIS APPLICATION FORM WITH THE REQUIRED DOCUMENTS SHALL MEAN APP-01
NON-INCLUSION IN THE LIST OF EXAMINEES IN THE ROOM ASSIGNMENT AND FORFEITURE OF EXAMINATION FEES Rev. 00
February 25, 2015
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