Republic of the Philippines Professional Regulation Commission Manila

STP Form A

APPLICATION FOR SPECIAL TEMPORARY PERMIT

INSTRUCTION :
This application must be accomplished bythe applicant or dulyauthorized representative. Anyfalse statement is subject to legal prosecution.
Passport size ID picture of the Applicant with COMPLETE Name Tag in plain white background

Category of STP applied for:

Profession:

Date of Filing

Part I
Surname:

Personal Data
Given Name/s: Maternal Name:

Visa / Nature of Stay Place of Birth Home address / country of origin:

Date of Birth

Citizenship

Gender

Civil Status

Date of Arrival Period of Stay

Philippine Mailing Address:

Contact Number or E-mail address: Name and Address of Sponsoring/Company/Institution in the Philippines: (If Applicable)

Contact Number or E-mail address: Have you ever been accused of, indicted, tried or convicted byanycourt of law, militarytribunal or administrative body? If so, attach a copyof the decision or the complaint, if still pending. No Yes

Part II

Professional Course Taken

College/ University Graduated Date Degree Conferred Honors, Distinctions or Awards Received

Title/ Degree Received

Part III

Specialization (State brieflyyour fields of specialization, special studies or courses taken)

Part IV

License/s Obtained (Inclusive of License Obtained in the Philippines)

Title of License Jurisdiction License/Certification Number Date issued / validity

Part V

Experience and Training

Position Held Employer Country or State

Dates of Service

Part VI- Sponsoring/Company/ Institution Profile

For Private Institutions:(SEC Registration) Nature of Business: Authorized Representative: For Government Institutions: Action taken by the Cashier Amount: __________________ OR No. __________________ Date: __________________ Signature of Cashier: ____________

Part VII- Acknowledgment

I HEREBY CERTIFY that the above information written by me are true and correct to the best of my knowledge and belief. And further authorize PRC and other government agencies to investigate the authenticity of all the documents presented. Signature of Applicant / Authorized Representative SUBSCRIBED AND SWORN to before me affiant exhibited to me the applicant's passport as indicated hereunder Passport Number: __________________________ Date of Issue: _________________ Place of Issue: _________________ Place and Date of Acknowldegment:

When and Where Prepared Notary Public P. PAREDES ST., CORNER N. REYES ST., SAMPALOC, MANILA, PHILIPPINES, 1008

P.O. BOX 2038, MANILA

Assessment and Evaluation of Requirements for Issuance of Special Temporary Permit

(FOR PRC PERSONNEL ONLY)

A. Special Temporary Permit Unit (Registration Division)

CategoryA CategoryB CategoryC CategoryD CategoryE CategoryF Foreignprofessionalsapplyingforregistrationwithorwithoutexaminationunderreciprocityorother internationalagreement. ForeignprofessionalstopracticeaprofessioninthePhilippinesunderreciprocityorotherinternational agreements. ForeignprofessionalswhoaretobeengagedbytheGovernmentasConsultantsinforeign-funded,joint venture,orforeignassistedprojects Foreignprofessionalswhoaretobeemployedbylocalandforeignprivatefirmsorinstitutionspursuantto law Foreignhealthprofessionalsforhumanitarianmissionforalimitedperiodoftime ForeignProfessionalsunderP.D.No.541,AllowingFormerFilipinoProfessionalstoPracticetheir RespectiveProfessionsinthePhilippines

General requirements applicable to all categories

1.[] 2.[] 3.[] STPApplicationFormdulyaccomplishedandnotarized Photocopyofvalidpassportasproofofcitizenship,identificationofvisaissued,proofofentryinthePhilippines PaymentofPrescribedFees

Additional requirements for: CategoryA

1.[] copyoftheinternationalagreementorlawofthestate/countryoftheapplicantshowingthattherequirementsforregistration orlicensingfromthecountryoforiginaresubstantiallythesameasthoserequiredandcontemplatedbythelawsofthe Philippines. anofficialdocumentissuedbytheappropriategovernmentoffice/agencycertifyingthattheapplicantisaregisteredprofessional therein copyoftheinternationalagreementorlawofthestate/countryoftheapplicantshowingthattherequirementsforregistration orlicensingfromthecountryoforiginaresubstantiallythesameasthoserequiredandcontemplatedbythelawsofthe Philippines. anofficialdocumentissuedbytheappropriategovernmentoffice/agencycertifyingthattheapplicantisaregisteredprofessional therein acopyoftheContractofConsultancyServicesoraMemorandumofAgreementbetweenthegovernmentagencyandthe foreignprofessionalindicatingtheTermsofReference,natureofconsultancy,period,scopeandprojectdetails.(Incaseofjoint venturebetweentwoprivateentities,anyofthepartiestheretoshallsubmittheapplication) Anofficialdocumentissuedbytheappropriategovernmentoffice/agencyoftheforeigncountry/statecertifyingthatthe applicantisaregisteredprofessionaltherein. acopyofthecontractofemployment,consultancyagreementorservicecontractincludingprojectdetails,scopeofworks, natureanddurationofengagementoftheforeignprofessionalandprofessionalliabilityinsurancewheneverapplicableand required. anofficialdocumentissuedbytheappropriategovernmentoffice/agencyoftheforeigncountry/statecertifyingtheapplicantisa registeredprofessionaltherein. aletterrequestfortheissuanceofSpecialTemporaryPermittotheforeignprofessionalfortheconductofhumanitarianmission withtheundertakingthatnofeeswillbecharged thelettermustindicatethevenueandthespecificdateofthehumanitarianmission acopyofapplicant'svalidpassportasproofofcitizenshipandproofofentryinthePhilippines anauthenticatedcopyofthevalidprofessionallicensesissuedbythecountryoforiginwithofficialEnglishtranslationthereof whennecessary Passportshowingname,picture,citizenshipanddateofentryinthePhilippineswhichmustbewithinsix(6)monthsbeforethe filingoftheapplicationforrenewal. theoriginalandphotocopyofthepreviouslyissuedProfessionalIdentificationCard adulyauthenticatedoriginalandphotocopyofthe License/CertificateofRegistration/Permitintheadoptedcountry. four(4)PassportsizeIDpictures.

2.[]

CategoryB
1.[]

2.[]

CategoryC
1.[]

2.[]

CategoryD
1.[]

2.[]

CategoryE
1.[]

2.[] 3.[]

CategoryF
1.[] 2.[] 3.[] 4.[]

Processedby:______________________________Verifiedby:_____________________________Date:_________________

B. ACTION BY THE PROFESSIONAL REGULATORY BOARD OF/FOR ________________________ BoardResolution STPCertificate ______________ Reg.No. _______________ Approved Disapproved STPID ________________

No.

IDNo.

Remarks: __________________________________________ __________________________________________

_________________________________________________

_________________________________ Chairman Date:________________

_______________________________________

ViceChairman