This Form is pre-numbered
NOT FOR SA LE
REPRODUCTION IS NOT ALLOWED
Republic of the Philippines
PRC App Form No. 001-A (Sept 2007)
Professional Regulation Commission
Manila
Application No. 1ST TIMER (NEW) REPEATER CONDITIONED
APPLICATION & QUALIFICATION EVALUATION DIVISION
NURSES APPLICATION FORM (NAF)
Regular B.S. Nursing With Other Degree/s
Place of Examination
Paste here your recent passport size picture with COMPLETE Name Tag in plain white background Scanned/Photocopied picture not accepted
Date of Examination
WARNING: All documents/statements submitted are subject to verification and any false statement or misrepresentation made in this appl ication is a gr ound f or disqual i fication and criminal pr osecution/administr ativ e sanction f or f alsi fication
PERRC No.
Part I - PERSONAL INFORMATION
SURNAME GIVEN NAME MIDDLE NAME M.I.
MALE FEMALE CITIZENSHIP SINGLE SEPARATED
COMPLETE MAILING ADDRESS (House No., Street, Town Prov./City)
ZIP CODE
Town/City/Prov RURBAN CODE
E-mail Address WIDOW/ER MARRIED LEGALLY DATE OF BIRTH
(mm/dd/yyyy)
Landline and Mobile No. (include area code)
PLACE OF BIRTH (City, Town Province)
ANNULLED DIVORCED
Town/City/Prov RURBAN CODE
SPOUSES NAME & CITIZENSHIP
FATHERS NAME & CITIZENSHIP
MOTHERS NAME & CITIZENSHIP
HAVE YOU EVER BEEN CONVICTED IN A FINAL JUDGMENT BY ANY COURT, MILITARY TRIBUNAL OR ADMINISTRATIVE BODY?
YES
NO
(If yes, attach hereto a copy of the decision)
Part II EDUCATIONAL INFORMATION
NAME of SCHOOL ADDRESS/LOCATION of SCHOOL PRC SCHOOL CODE
DEGREE/COURSE OBTAINED
PRC COURSE CODE
B. S. Nursing
OTHER EDUCATIONAL ATTAINMENT
4018
DATE GRADUATED (mm/dd/yy)
PRC BOARD CODE
2600
Degree/Course
1st 2nd 3rd
prior to BS Nursing
NAME of SCHOOL
PRC SCHOOL CODE
ADDRESS/LOCATION of SCHOOL
DATE GRADUATED
(mm/dd/yyyy)
REVIEW SCHOOL/CENTER ATTENDED
Part III PREVIOUS NURSES LICENSURE EXAMINATION/S TAKEN
NAME of EXAMINATION PLACE of EXAM DATE TAKEN RESULT OF EXAMINATION (Pls. check) RATING PASSED FAILED COND. EXAM NO VERIFIED BY
STATUS CODES
(refer at the back) :
1.) EXAMINATION TYPE (EX CODE)
2.) NUMBER of TIMES TAKEN (NX CODE) ACTION TAKEN BY THE LEGAL DIVISION/OFFICER Processed by: Date: Remarks:
I HEREBY CERTIFY that the information and/or statements in this application including the exhibits submitted in support thereof are all true and correct of 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. I AM WILLING TO TAKE A VALIDATING EXAMINATION IN CASE THE TEST RESULTS IN MY PLACE OF EXAMINATION ARE STATISTICALLY IMPRORABLE.
ACTION TAKEN BY THE APPLICATION PROCESSOR Processed by: Date: Remarks:
ACTION TAKEN BY THE CASH SECTION
ACTION TAKEN BY THE BOARD Chairman: Member: Member: Remarks: ACTION TAKEN BY THE ISSUING OFFICER Issued by: Date: Remarks:
Signature
RIGHT THUMBMARK
Amount: O.R. No: Date: Issued by:
Date
Metered Documentary Stamp
Subscribed and sworn to before me this day of 20_____ at ______________. Affiant applicant exhibited to me his/her Community Tax Certificate No. _______________________ issued at ________________________ on __________________.
print this form using LASER or INKJET printer having BEST or NORMAL print setting & FIT TO PAPER in 8.5 x 14 (legal size) paper
PRC Administering Officer
print this form using LASER or INKJET printer having BEST or NORMAL print setting & FIT TO PAPER in 8.5 x 14 (legal size) paper
CHECKLIST OF REQUIREMENTS
NSO Birth Certificate
(ORIGINAL and PHOTOCOPY)
OTHER REQUIREMENTS a.) Examination Fee Php : 900.00 (complete)/ 450.00 (conditioned) b.) 4 pcs passport pictures in white background with complete name tag c.) 1 piece window mailing envelope with metered postage stamp d.) Current Community Tax Certificate (cedula)
NSO Marriage Contract (female married applicant) Transcript of Records with degree/course, exact date of graduation , Special Order (S.O)/exemption/accreditation/deregulation status, SCANNED PICTURE and remarks FOR BOARD EXAMINATION PURPOSES ONLY Summary of Related Learning Experience (with total number of hours) Record of O.R-D.R Cases CHED Recognition or permit to operate for graduates of new schools/programs
STEPS in APPLYING for LICENSURE EXAMINATION
STEP 1: Secure Nurses Application Form (NAF) at the Information Desk or download from www.prc.gov.ph STEP 2: Fill-up Application Form and proceed to Processing Counters (windows 5,6,7,8) or other designated counters. For : OTHER DEGREE HOLDER/2ND COURSER - proceed to the Rating Division for interview by the Board of Nursing; Regional Filing Center - submit and return at appointed schedule REPEATER/CONDITIONED - proceed to Records Section/Unit for rating/result verification REPEATER WITH CHANGE OF CIVIL STATUS - proceed to the Asst. Secretariats office for change status approval FOREIGN SOUNDING SURNAME/BORN ABROAD/FOREIGN PARENT/S : proceed to Legal Division/Unit for approval of citizenship STEP 3: Pay examination fee at the Cashiers Counters (windows 1,2,3,4) or other designated counters. STEP 4: Accomplish all PRC Forms. Copy Application Number on the Notice of Admission. STEP 5: Proceed to the Customer Service Center/ PRC Coop Store for the metered stamps and window mailing envelope. STEP 6: Proceed to the Issuance Counters (windows 9,10,11,12) or other designated counters. STEP 7: Return to PRC 2-3 days before the exam date for verification of school/building/room assignment.
RURBAN CODES/SCHOOL CODES/COURSE CODES/BOARD CODES/STATUS CODES
1. Refer to the MASTERLIST of ADDRESS/RURBAN CODES posted at the premises of the filing center for the CODES of the Town, City or Province of your Residence and Postal Address and Place of Birth . This is different from the ZIP CODE. 2. Refer to the MASTERLIST of SCHOOL CODES also posted at the filing center for the School /College/University and Location 3. Refer to the MASTERLIST of COURSE CODES for the Course Code. 4. For STATUS CODES, use the following: a. EX CODE - Examination Type Code Print 1 for Complete/First Timer Print 2 for Repeaters Print 3 for Removal/Conditioned b. NX CODE - Number of Times Taken Print 0 for None Print 1 for Once Print 2 for Twice... and so on
IMPORTANT
1. Keep and bring your Notice of Admission with Official Receipt, window mailing envelope securely stapled. Application Number will be used when you fill up the Identification Sheet on the day of examination. 2. Bring pencils (No. 2), ballpen (with black ink only), one piece (1) big brown envelope, one long transparent plastic envelope. 3. Report to your school assignment before 6:00 a. m. on examination days. Late examinees will not be admitted. This will mean forfeiture of examination fee.
O-Lic/APPLIC
ATE/PDS/aamb092007
