Dummy PERRC Only

PRC Form No.03 (Rev03/03/2004)

NOT FOR SALE
REPRODUCTION NOT ALLOWED Deficiency Code : __________
PROFESSION / BOARD OF Lifting Reference : __________
Entered by : ___________
(To be printed in BOLD letters personally by applicant)
Paste here
your recent LAST NAME FIRST NAME MIDDLE NAME MIDDLE
1½x1½ INITIAL
Colored picture with
Residence/Complete Mailing Address
Complete name tag
In plain white
background Date of Birth (mm/dd/yy) Place Of Birth (City/Town/Province)

IMPOSTOR WILL
BE PROSECUTED Citizenship Single Widow/er Male Spouse’s Name and Citizenship
Married Separated Female
Father’s Name and Citizenship Mother’s Name and Citizenship
I hereby certify that
all information that I Date Graduated (mm/yyyy)
School Attended/Location Degree / Course Completed
have written herein are
true and correct of my
own knowledge and
that I am fully aware EXAMINATION RECORD REMARKS / SUBJECTS TO BE TAKEN
that any false (To be filled up by PRC) (To be filled up by PRC)
information renders me Date Taken Rating P/F/Cond Exam No Recorded by (signature)
liable for criminal Subj. 1. ___________________
prosecution. 1. Subj. 2. ___________________
_______________ 2. Subj. 3. ___________________
(Signature) Recorded by :
3.
4 (Printed Name and Signature)

Subscribed and sworn to before this _______day of ___________ 20 ____ at _______________. Affiant applicant
exhibited to me his Community Tax Certificate No. _______________ issued at _______________ on
(Right Thumbmark) ____________________.
__________________________________
PRC Administering Officer

! " # $% " &&&&&&&&&&&&&&&&

Dummy PERRC Only

PRC Form No.03 (Rev03/03/2004)

NOT FOR SALE
REPRODUCTION NOT ALLOWED Deficiency Code : __________
PROFESSION / BOARD OF Lifting Reference : __________
Entered by : ___________
(To be printed in BOLD letters personally by applicant)
Paste here
your recent LAST NAME FIRST NAME MIDDLE NAME MIDDLE
1½x1½ INITIAL
Colored picture with
Residence/Complete Mailing Address
Complete name tag
In plain white
background Date of Birth (mm/dd/yy) Place Of Birth (City/Town/Province)

IMPOSTOR WILL
BE PROSECUTED Citizenship Single Widow/er Male Spouse’s Name and Citizenship
Married Separated Female
Father’s Name and Citizenship Mother’s Name and Citizenship
I hereby certify that
all information that I Date Graduated (mm/yyyy)
School Attended/Location Degree / Course Completed
have written herein are
true and correct of my
own knowledge and
that I am fully aware EXAMINATION RECORD REMARKS / SUBJECTS TO BE TAKEN
that any false (To be filled up by PRC) (To be filled up by PRC)
information renders me Date Taken Rating P/F/Cond Exam No Recorded by (signature)
liable for criminal Subj. 1. ___________________
prosecution. 1. Subj. 2. ___________________
_______________ 2.
Subj. 3. ___________________
(Signature) Recorded by :
3.
4 (Printed Name and Signature)

Subscribed and sworn to before this _______day of ___________ 20 ____ at _______________. Affiant applicant
exhibited to me his Community Tax Certificate No. _______________ issued at _______________ on
(Right Thumbmark) ____________________.
__________________________________
PRC Administering Officer

! " # $% " &&&&&&&&&&&&&&&&