Republic of the Philippines

 ORIGINAL
Professional Regulation Commission
paste your
 DUPLICATE Lucena City passport size
 REPRINT   picture with
nametag here
 REPLACEMENT
BOARD CERTIFICATE REQUEST FORM
Please fill all blanks:
SURNAME FIRST NAME MIDDLE NAME MAIDEN NAME
License/Registration No. Date of Registration:
FOR TEACHERS: OTHER PROFESSIONS:
[ ] LET Passer [ ] Elementary
(mm/yyyy) [ ] Secondary Name of Profession Date of Examination
[ ] PBET Passer/Magna Carta (Res. No.) Amount: O.R. No:
Contact Number: O.R. Date: Issued by:
Instructions:
Requirements:
 1 piece passport size picture with name tag (last 1. Fill up the request form.
name, first name, middle name) 2. Submit request form with the requirements at
 Photocopy of Updated Professional Identification Window 1  2 for Various Professions;
Card/License (for old registrant only) Window 3, 4,  5 for Nurses; Window 6, 7,
 8 for Teachers.
Date Filed:    

CLAIM STUB FOR BOARD CERTIFICATE

Registered Name: Received by:
License / Registration No.: Date of Registration: Date Filed:
Remarks: Follow up your board certificate after six months. Telephone No. (042) 373.73.16

Note: REPRESENTATIVES WITH PROPER IDENTIFICATION SHOULD PRESENT SPECIAL POWER OF

ATTORNEY FROM THE REGISTERED PROFESSIONAL AND THIS ORIGINAL CLAIM SLIP.