Anda di halaman 1dari 10

Page 01 of 10

University of Cebu
College of Nursing – Banilad Campus
Governor Cuenco Avenue, Banilad
Cebu City

Name of Student: _ __DAVID, CALVIN KLEIN A._ _ _ _____________________________________________________________________________________________________________________________________________


Name & Address of School: ____ University of Cebu – Banilad Governor Cuenco Avenue, Banilad, Cebu City__________________________________________________________________________________________________________
Accreditation Level (if any): ______ Level II – Third Reaccredited Status_______ ________________________________________________________________ Year Granted: 2007__________________________________________
First Course (if any): Not Applicable____________________________________________________School Graduated From: Not Applicable_____________________ Year: Not Applicable____________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: ___2006___________________________________________________________________________ _________________________________________________________
Year Graduated (BSN Program): ________2010___________________________________________________________________________________________________ _______________________________________________________

I. Major Operations
Signature of
No Date of Type of Name of O.R.
Case No. Name of Patient Diagnosis Operation Performed Name of Surgeon Name of Hospital O.R. Scrub
. Operation Anesthesia Scrub Nurse
Nurse
Associated Marine
Hydrops Gallbladder Acute Officers and
Cresencia C. Lagura Laparoscopic Manuel B. Villamor, April Angeli E. Ang,
07/07/2009 01-3624 And Chronic Cholecystitis with General Seamen's Union of
1 Cholecystectomy M.D. R.N.
severe adhesions the Philippines
Hospital
Associated Marine
Officers and
Manuel B. Villamor, Christopher M.
07/16/2009 02-8344 Marlo T. Mesagrande Variocoele Left Variocoelectomy Left Regional Seamen's Union of
2 M.D. Apas, R.N.
the Philippines
Hospital
Associated Marine
Secondary to benign Prostatic Officers and Robert John T.
Cysto-Transurethral
3 07/14/2009 01-8605 Leonardo E. Oyao Hyperplasia Status Post Prostate Regional Alan G.Mejarito, M.D. Seamen's Union of Salahog,
Resection of Prostate
Biopsy the Philippines R.N.
Hospital
Pregancy Uterine Delivered By
Cesarean Section Secondary to Primary Low Segment Visayas
Dolores D.Del Mar,
4 02/19/2010 57173 Salvacion T. Punay Placenta Previa, Transverse Cesarean Regional Roland H. Yu, M.D. Community
R.N.
Totalis,Term,Cephalic Live Birth Section Medical Center
G7P4(4034)
Total Abdominal
Hysterectomy Bilateral
Endometriosis Adenocarcinoma Visayas
02/ 25/2010 201002240 Monalisa G. Tudtud Salpingo Oophorectomy Tabetha S. Galindo, John Paul G.
5 Stage 1 General Community
00018 + Bilateral Lymph Node M.D. Cabrera,R.N.
Medical Center
Disection+ Peritonial
Fluid Cytology

Prepared by:

DAVID, CALVIN KLEIN A._


Name of Student
Page 03 of 10

University of Cebu
College of Nursing – Banilad Campus
Governor Cuenco Avenue, Banilad
Cebu City

Name of Student: __ _DAVID,CALVIN KLEIN A.____ ______________________________________________________________________________________________________________________________


Name & Address of School: ____ University of Cebu – Banilad Governor Cuenco Avenue, Banilad, Cebu City__________________________________________________________________________________________________________
Accreditation Level (if any): ______ Level II – Third Reaccredited Status_______ ________________________________________________________________ Year Granted: 2007__________________________________________
First Course (if any): Not Applicable____________________________________________________School Graduated From: Not Applicable_____ _______________ Year: Not Applicable____________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: ___2006_____________________________________________________________________________________________________________________________________
Year Graduated (BSN Program): ________2010___________________________________________________________________________________________________________________________________________________________

II. Minor Operations


Signature of
No Date of Type of Name of O.R.
Case No. Name of Patient Diagnosis Operation Performed Name of Surgeon Name of Hospital O.R. Scrub
. Operation Anesthesia Scrub Nurse
Nurse
Associated Marine
Officers and
Fractional Dilation and Felissa Grace del Karen G. Sinadjan,
1 07/ 08/2009 03-0725 Evajin P. Anivado Incomplete Abortion Local Seamen's Union of
Curettage Rosario, M.D. R.N.
the Philippines
Hospital

Clarita B. Alcantara, Visayas community Vin Franz I. Nery,


2 02/25/2010 306057 Marissa M. Mejares Incomplete Abortion Completion Curettage General
M.D. Medical Center R.N.

Cebu Puericulture
Pregnancy Uterine Full
03/17/2010 SG-05 Raida G. Varona, And Maternity Rhodora M. Ulila,
3 Fontainne Mae A. Bataluna Episioraphy Term With Midline Local
M.D. House, R.N.
Episiotomy Repaired
Incorporated

Prepared by:

DAVID, CALVIN KLEIN A.


Name of Student
Page 05 of 10

University of Cebu
College of Nursing – Banilad Campus
Governor Cuenco Avenue, Banilad
Cebu City

Name of Student: ___ ___DAVID, CALVIN KLEIN A._ _____________________________________________________________________________________________________________________________________________


Name & Address of School: ____ University of Cebu – Banilad Governor Cuenco Avenue, Banilad, Cebu City__________________________________________________________________________________________________________
Accreditation Level (if any): ______ Level II – Third Reaccredited Status_______ ________________________________________________________________ Year Granted: 2007__________________________________________
First Course (if any): Not Applicable____________________________________________________School Graduated From: Not Applicable_____________________Year: Not Applicable____________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: ___2006______________________________________________________________________________________________________________________________________
Year Graduated (BSN Program): ________2010___________________________________________________________________________________________________________________________________________________________

III. Actual Deliveries


Supervised by:
No Date of Time of Gender
Case No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery Name & Signature of
. Delivery Delivery of Baby
Qualified C.I.

003 Pregnancy Uterine Full Term Normal Spontaneous


1 Venita B.Pono 29 01/06/09 12:30 Female Dra. Veronica N. Alivio's Lying-in Ms. Lucineil M.
Age of Gestation: 40 weeks and 6 days Vaginal Delivery
PM Clinic Gabayeron, R.N.

Pregnancy Uterine Full Term 7:35 Male Cebu Puericulture Center And Normal Spontaneous Ms. Ramelda G.
2 042692/10
Age of Gestation: 39 weeks Candice M. Antonio 27 01/28/10 AM Maternity House ,Incorporated Vaginal Delivery Villarazo, R.N.

Pregnancy Uterine Full Term 05:00 Male Dra. Veronica N. Alivio's Lying-in Normal Spontaneous Ms. Tyrene R.
3 132 Edith C. Cagais
Age of Gestation: 37 weeks and 1 Day 30 03/18/10 AM Clinic Vaginal Delivery Mangubat,R.N.

Pregnancy Uterine Full Term 03:55 Dra. Veronica N. Alivio's Lying-in Normal Spontaneous Ms. Tyrene R.
133 Genevieve C. Paquiao
4 Age of Gestation: 42 weeks and 2 Days 35 03/19/10 AM Female Clinic Vaginal Delivery Mangubat,R.N.

Pregnancy Uterine Full Term 12:52 Dra. Veronica N. Alivio's Lying-in Normal Spontaneous Ms. Tyrene R.
5 136 Rosemarie M. Formentera
Age of Gestation: 42 weeks and 1 Day 28 03/20/10 AM Female Clinic Vaginal Delivery Mangubat,R.N.

Prepared by:

DAVID, CALVIN KLEIN A.__


Name of Student
Page 07 of 10

University of Cebu
College of Nursing – Banilad Campus
Governor Cuenco Avenue, Banilad
Cebu City

Name of Student: ___ __DAVID, CALVIN KLEIN A.__ _______ ______________________________________________________________________________________________________________________________________


Name & Address of School: ____ University of Cebu – Banilad Governor Cuenco Avenue, Banilad, Cebu City__________________________________________________________________________________________________________
Accreditation Level (if any): ______ Level II– Third Reaccredited Status_______ ________________________________________________________________ Year Granted: 2007__________________________________________
First Course (if any): Not Applicable____________________________________________________School Graduated From: Not Applicable_____________________Year: Not Applicable____________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: ___2006 _____________________________________________________________________________________________________________________________________
Year Graduated (BSN Program): ________2010___________________________________________________________________________________________________________________________________________________________

IV. Deliveries Assisted


Supervised by:
No Date of Time of Gender
Case No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery Name & Signature of
. Delivery Delivery of Baby
Qualified C.I.

015 Pregnancy Uterine Full Term 1:05 Dra. Veronica N. Alivio's Lying-in Normal Spontaneous Ms. Lucineil M.
1 Danica D. Ejandra 19 01/ 18/2009 Male
Age of Gestation: 38 weeks and 6 days PM Clinic Vaginal Delivery Gabayeron, R.N.

Associated Marine Officers and


Pregnancy Uterine Full Term 5:09 Normal Spontaneous Mr. Meil CarloC.
2 02-8091 Cherry Rose D. Oyao 25 07/03/2009 Female Seamen's Union of the Philippines
Age of Gestation: 41 weeks and 5 days PM Vaginal Delivery Judaya,R.N.
Hospital

04-99-10 Pregnancy Uterine Full Term 10:17 Normal Spontaneous Ms. Cristy B. Tecson,
3 Maria Lourdes H. Ricablanca 20 08/10/2009 Male Barili District Hospital
Age of Gestation: 37 weeks and 4 days AM Vaginal Delivery R.N.

200912090 Pregnancy Uterine Full Term


Maria Katrina Merlinda T. 7:40 Visayas Community Medical Normal Spontaneous Ms. Sheila O. Anoling,
4 00014 Age of Gestation: 40 weeks and 6 days 24 12/09/2009 Male
Manligis PM Center Vaginal Delivery R.N.

Pregnancy Uterine Full Term


12:24 Cebu Puericulture Center And Normal Spontaneous Ms. Cristy B.
057134 Age of Gestation: 38 weeks and 5 days Josam May S Llanos 28 02/18/2010 Female
5 PM Maternity House ,Incorporated Vaginal Delivery Tecson,R.N.

Prepared by:

DAVID, CALVIN KLEIN A.__


Name of Student
Page 09 of 10

University of Cebu
College of Nursing – Banilad Campus
Governor Cuenco Avenue, Banilad
Cebu City

Name of Student: ___ ___DAVID, CALVIN KLEIN A.__ ____ __________________________________________________________________________________________________________________________________________


Name & Address of School: ____ University of Cebu – Banilad Governor Cuenco Avenue, Banilad, Cebu City__________________________________________________________________________________________________________
Accreditation Level (if any): ______ Level II – Third Reaccredited Status_______ ________________________________________________________________ Year Granted: 2007__________________________________________
First Course (if any): Not Applicable____________________________________________________School Graduated From: Not Applicable_____________________Year: Not Applicable____________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: ___2006______________________________________________________________________________________________________________________________________
Year Graduated (BSN Program): ________2010___________________________________________________________________________________________________________________________________________________________

V. Cord Dressing
Supervised by:
No Gender of
Case No. Date Performed Name of Baby Name of Mother Age Name of Hospital Name & Signature of
. Baby
Qualified C.I.

1 05/14,/2009 Baby Girl Belonguil Female Clarice L. Belonguil 27 St. Vincent General Hospital Ms. Marites S. Tarucan, R.N.
040327

310722
2 03/25/10 Baby Girl Geolin Female Jeje C. Geolin 23 Visayas Community Medical Center Ms.Debbie A. Ibarra, R.N.

310746
3 01/16/2010 Baby Girl Pilapil Female Edelyn T. Pilapil 28 Visayas Community Medical Center Ms. Sheila O. Anoling, R.N.

Cebu Puericulture Center And Maternity


4 03/17/2010 Baby Boy Vergara Male Jessa May E.Vergara 19 Ms. Deborah G. Gemao,R.N.
57818 House ,Incorporated

57820 Cebu Puericulture Center And Maternity


5 03/17/2010 Baby Girl Alsola Female Richel T. Alsola 21 Ms. Deborah G. Gemao, R.N.
House ,Incorporated

Prepared by:

DAVID, CALVIN KLEIN A.__


Name of Student
Page 04 of 10
Supervised by:
Noted by: Concurred by: Concurred by:
MS. MA. ESTELLA P. CABATAÑA
Signature over printed name of Faculty MS. PILUCHI VICTORINA M. VILLEGAS__ _ ______ MS. NORBETA N. MAYOL_________________ DR. EVALOUR O. MEDRANO ___ _____
Date Signed: _ ____________________ Signature over printed name of Clinical Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse
Degree: _____RN, MN ______________ Coordinator Date Signed: __________________________ Date Signed: _________________________
a.) PRC No.: __0155542 ______ Date Signed: ________________________ ______ Degree: _______RN, MAN________________ Degree: ______RN, MAN, Ed.D___________
Valid until: _May 17, 2011 _ Degree: _____RN, MN_________________ ______ a.) PRC No.: ____0117783________________ a.) PRC No.: ___0173592______ _____
b.) PNA No.: _ 1496___________ a.) PRC No.: __0120467______________________ Valid until: ___June 01, 2012___________ Valid until: __May 28, 2012__ __
Valid until: _Lifetime______________ Valid until: _November 8, 2010______________ b.) PNA No.: ____1536___________________ b.) PNA No.: ___11651_________ ______
b.) PNA No.: __16459________________________ Valid until: ___Lifetime________________ Valid until: __ Lifetime___ __
Valid until: _Lifetime_______________________ c.) ANSAP No.: __0330__________________ c.) ANSAP No.: __04818________ _______
Valid until: ___Lifetime_________________ Valid until: __ _December 31, 2010_____

Concurred by: Approved by:

MS. ELENA M. JUMAO-AS___ ________ ___ DR. HELEN C. ESTRELLA________________


Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed: _ _______________________ Date Signed: _________________________
Degree: ______RN __________________ Degree: ______RN, MN, DM_____________
a.) PRC No.: __ 0125547 _______________ a.) PRC No.: __ 0075238 _______________
Valid until: _ February 21, 2011 ________ Valid until: __June 19, 2011___________
b.) PNA No.: __ 015167 _ _______________ b.) PNA No.: __ 2764 __________________
Valid until: _ December 31, 2012 _ __ ___ Valid until: __Lifetime________________
c.) ANSAP No.: _04864 _________________ c.) ADPCN No.: 0733(ADPCN)____________
Valid until: _ December 31, 2010 ______ Valid until: __December 31, 2010_______

I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct, and complete statement pursuant to the provisions of
pertinent laws, rules and regulations of the republic of the Philippines.

____DAVID, CALVIN KLEIN A.


Signature of Applicant

Subscribed and sworn to before me this _______ day of ______________________ 2010, ___________________________________________ Philippines.
Concurred by:
Concurred by:
DR. EVALOUR O. MEDRANO ___ _____
Supervised by: Noted by: NOTARY PUBLIC Signature over printed name of Chief Nurse
MS. NORBETA N. MAYOL_________________
Signature over printed name of Chief Nurse Date Signed: _________________________
MS. MA. ESTELLA P. CABATAÑA MS. PILUCHI VICTORINA M. VILLEGAS__ _ ______ Date Signed: __________________________ Degree: ______RN, MAN, Ed.D___________
Signature over printed name of Faculty Signature over printed name of Clinical Degree: _______RN, MAN________________ a.) PRC No.: ___0173592______ _____
Date Signed: _ ____________________ Coordinator a.) PRC No.: ____0117783________________ Valid until: __May 28, 2012__ __
Degree: _____RN, MN ______________ Date Signed: ________________________ ______ b.) PNA No.: ___11651_________ ______ Page 02 of 10
Valid until: ___June 01, 2012___________
a.) PRC No.: __0155542 ______ Degree: _____RN, MN_________________ ______ b.) PNA No.: ____1536___________________ Valid until: __ Lifetime___ __
Valid until: _May 17, 2011 _ a.) PRC No.: __0120467______________________ Valid until: ___Lifetime________________ c.) ANSAP No.: __04818________ _______
b.) PNA No.: _ 1496___________ Valid until: _November 8, 2010______________ c.) ANSAP No.: __0330__________________ Valid until: __ _December 31, 2010_____
Valid until: _Lifetime______________ b.) PNA No.: __16459________________________ Valid until: ___Lifetime_________________
Valid until: _Lifetime_______________________
Approved by:

DR. HELEN C. ESTRELLA________________


Signature over printed name of Dean
Date Signed: _________________________
Degree: ______RN, MN, DM_____________
a.) PRC No.: __ 0075238 _______________
Valid until: __June 19, 2011___________
b.) PNA No.: __ 2764 __________________
Valid until: __Lifetime________________
c.) ADPCN No.: 0733(ADPCN)____________
Valid until: __December 31, 2010_______

I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct, and complete statement pursuant to the provisions of
pertinent laws, rules and regulations of the republic of the Philippines.

____DAVID, CALVIN KLEIN A.


Signature of Applicant

Subscribed and sworn to before me this _______ day of ______________________ 2010, ___________________________________________ Philippines.

Approved by:
NOTARY PUBLIC
Concurred by:
DR. HELEN C. ESTRELLA________________
Supervised by: Noted by: MS. ELENA M. JUMAO-AS___ ________ ___ Signature over printed name of Dean
Signature over printed name of Chief Nurse Date Signed: _________________________
MS. MERCY MILAGROS B. APUHIN_____ MS. PILUCHI VICTORINA M. VILLEGAS__ _ ______ Degree: ______RN, MN, DM_____________ Page 06 of 10
Date Signed: _ _______________________
Signature over printed name of Faculty Signature over printed name of Clinical Degree: ______RN __________________ a.) PRC No.: __ 0075238 _______________
Date Signed: ______________________ Coordinator a.) PRC No.: __ 0125547 _______________ Valid until: __June 19, 2011___________
Degree: _____RN, MN_______________ Date Signed: ________________________ ______ Valid until: _ February 21, 2011 ________ b.) PNA No.: __ 2764 __________________
a.) PRC No.: __0125696 _____________ Degree: _____RN, MN_________________ ______ b.) PNA No.: __ 015167 _ _______________ Valid until: __Lifetime________________
Valid until: _November 04, 2010_____ a.) PRC No.: __0120467______________________ Valid until: _ December 31, 2012 _ __ ___ c.) ADPCN No.: 0733(ADPCN)____________
b.) PNA No.: _ 14968________________ Valid until: _November 8, 2010______________ c.) ANSAP No.: _04864 _________________ Valid until: __December 31, 2010_______
Valid until: _Lifetime ______________ b.) PNA No.: __16459________________________ Valid until: _ December 31, 2010 ______
Valid until: _Lifetime_______________________
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct, and complete statement pursuant to the provisions of
pertinent laws, rules and regulations of the republic of the Philippines.

____DAVID, CALVIN KLEIN A.


Signature of Applicant

Subscribed and sworn to before me this _______ day of ______________________ 2010, ___________________________________________ Philippines.

NOTARY PUBLIC

Concurred by:
Page 08of 10Concurred by:
Supervised by: Noted by: MS. NORBETA N. MAYOL_________________ MS. HAZEL C. ALQUIZOLA___ _____
Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse
MS. MERCY MILAGROS B. APUHIN_____ MS. PILUCHI VICTORINA M. VILLEGAS__ _ ______ Date Signed: __________________________ Date Signed: _________________________
Signature over printed name of Faculty Signature over printed name of Clinical Degree: _______RN, MAN________________ Degree: ______RN______________ _
Date Signed: ______________________ Coordinator a.) PRC No.: ____0117783________________ a.) PRC No.: __0316676_______ _____
Degree: _____RN, MN_______________ Date Signed: ________________________ ______ Valid until: ___June 01, 2012___________ Valid until: __ ____ ___
a.) PRC No.: __0125696 _____________ Degree: _____RN, MN_________________ ______ b.) PNA No.: ____1536___________________ b.) PNA No.: __014418____ ______
Valid until: _November 04, 2010_____ a.) PRC No.: __0120467______________________ Valid until: ___Lifetime________________ Valid until: _January 31, 2011_
b.) PNA No.: _ 14968________________ Valid until: _November 8, 2010______________ c.) ANSAP No.: __0330__________________ c.) ANSAP No.: 03676_______________
Valid until: _Lifetime ______________ b.) PNA No.: __16459________________________ Valid until: ___Lifetime_________________ Valid until: _January 31 2011___
Valid until: _Lifetime_______________________
Concurred by: Concurred by: Approved by:
DR. EVALOUR O. MEDRANO ___ _____ MS. ELENA M. JUMAO-AS___ ________ ___ DR. HELEN C. ESTRELLA________________
Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed: _________________________ Date Signed: _ _______________________ Date Signed: _________________________
Degree: ______RN, MAN, Ed.D___________ Degree: ______RN __________________ Degree: ______RN, MN, DM_____________
a.) PRC No.: ___0173592______ _____ a.) PRC No.: __ 0125547 _______________ a.) PRC No.: __ 0075238 _______________
Valid until: __May 28, 2012__ __ Valid until: _ February 21, 2011 ________ Valid until: __June 19, 2011___________
b.) PNA No.: ___11651_________ ______ b.) PNA No.: __ 015167 _ _______________ b.) PNA No.: __ 2764 __________________
Valid until: __ Lifetime___ __ Valid until: _ December 31, 2012 _ __ ___ Valid until: __Lifetime________________
c.) ANSAP No.: __04818________ _______ c.) ANSAP No.: _04864 _________________ c.) ADPCN No.: 0733(ADPCN)____________
Valid until: __ _December 31, 2010_____ Valid until: _ December 31, 2010 ______ Valid until: __December 31, 2010_______

I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct, and complete statement pursuant to the provisions of
pertinent laws, rules and regulations of the republic of the Philippines.

____DAVID, CALVIN KLEIN A.


Signature of Applicant

Subscribed and sworn to before me this _______ day of ______________________ 2010, ___________________________________________ Philippines.

NOTARY PUBLIC

Page 10 of 10
Concurred by:
Concurred by:
Supervised by: DR. EVALOUR O. MEDRANO ___ _____
Noted by: Signature over printed name of Chief Nurse
MS. MAE SOCORRO M. SEGUERRA ________
MS. MERCY MILAGROS B. APUHIN_____ Signature over printed name of Chief Nurse Date Signed: _________________________
MS. PILUCHI VICTORINA M. VILLEGAS__ _ ______ Degree: ______RN, MAN, Ed.D___________
Signature over printed name of Faculty Signature over printed name of Clinical Date Signed: _________________________
Date Signed: ______________________ Degree: ______RN, MAN _______________ a.) PRC No.: ___0173592______ _____
Coordinator Valid until: __May 28, 2012__ __
Degree: _____RN, MN_______________ Date Signed: ________________________ ______ a.) PRC No.: ___0164357________________
a.) PRC No.: __0125696 _____________ Valid until: __May 06, 2012 _______ b.) PNA No.: ___11651_________ ______
Degree: _____RN, MN_________________ ______ Valid until: __ Lifetime___ __
Valid until: _November 04, 2010_____ a.) PRC No.: __0120467______________________ b.) PNA No.: ___17845__________________
b.) PNA No.: _ 14968________________ Valid until: __Lifetime ________ c.) ANSAP No.: __04818________ _______
Valid until: _November 8, 2010______________ Valid until: __ _December 31, 2010_____
Valid until: _Lifetime ______________ b.) PNA No.: __16459________________________ c.) ANSAP No.: _______________ ____
Valid until: _Lifetime_______________________ Valid until: _______ __
Concurred by: Approved by:

MS. ELENA M. JUMAO-AS___ ________ ___ DR. HELEN C. ESTRELLA________________


Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed: _ _______________________ Date Signed: _________________________
Degree: ______RN __________________ Degree: ______RN, MN, DM_____________
a.) PRC No.: __ 0125547 _______________ a.) PRC No.: __ 0075238 _______________
Valid until: _ February 21, 2011 ________ Valid until: __June 19, 2011___________
b.) PNA No.: __ 015167 _ _______________ b.) PNA No.: __ 2764 __________________
Valid until: _ December 31, 2012 _ __ ___ Valid until: __Lifetime________________
c.) ANSAP No.: _04864 _________________ c.) ADPCN No.: 0733(ADPCN)____________
Valid until: _ December 31, 2010 ______ Valid until: __December 31, 2010_______

I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct, and complete statement pursuant to the provisions of
pertinent laws, rules and regulations of the republic of the Philippines.

____DAVID, CALVIN KLEIN A.


Signature of Applicant

Subscribed and sworn to before me this _______ day of ______________________ 2010, ___________________________________________ Philippines.

NOTARY PUBLIC