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    Renewal Form

    Uploaded by

    Jret Ilas
    This document is an application form for a Professional Identification Card (PIC) from the Professional Regulation Commission of the Philippines. It contains personal information about the applicant such as name, date of birth, address, profession, license number, and declaration that the information provided is true. The applicant also acknowledges that any false statements could lead to rejection or cancellation of the PIC. For those who did not meet continuing professional development requirements, there is an undertaking to submit the remaining credits for the next renewal period. Guidelines are also provided about authorization for representatives and appointment dates.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd

    Renewal Form

    Uploaded by

    Jret Ilas
    24 views4 pages
    This document is an application form for a Professional Identification Card (PIC) from the Professional Regulation Commission of the Philippines. It contains personal information about the applicant such as name, date of birth, address, profession, license number, and declaration that the information provided is true. The applicant also acknowledges that any false statements could lead to rejection or cancellation of the PIC. For those who did not meet continuing professional development requirements, there is an undertaking to submit the remaining credits for the next renewal period. Guidelines are also provided about authorization for representatives and appointment dates.

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    Renewal Form (2)

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    This document is an application form for a Professional Identification Card (PIC) from the Professional Regulation Commission of the Philippines. It contains personal information about the applicant such as name, date of birth, address, profession, license number, and declaration that the information provided is true. The applicant also acknowledges that any false statements could lead to rejection or cancellation of the PIC. For those who did not meet continuing professional development requirements, there is an undertaking to submit the remaining credits for the next renewal period. Guidelines are also provided about authorization for representatives and appointment dates.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    24 views4 pages

    Renewal Form

    Uploaded by

    Jret Ilas
    This document is an application form for a Professional Identification Card (PIC) from the Professional Regulation Commission of the Philippines. It contains personal information about the applicant such as name, date of birth, address, profession, license number, and declaration that the information provided is true. The applicant also acknowledges that any false statements could lead to rejection or cancellation of the PIC. For those who did not meet continuing professional development requirements, there is an undertaking to submit the remaining credits for the next renewal period. Guidelines are also provided about authorization for representatives and appointment dates.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    You are on page 1of 4

    Professional Regulation Commission

    APPLICATION FOR PROFESSIONAL IDENTIFICATION CARD (PIC)

    TIME RECEIVED:
    APOINTMENT DATE:: September 28,2021(01:00PM TO 02:00PM) PRC BAGUIO
    -PLACE/O.R. NO. REOZIT6FZMPD /AMOUNT: PHP 450.00 TIME RELEASED: ___________________
    NAME ILAS ,JANICE DAGDAG TEL No./CP No. 09121297683

    Last Name First Name Middle Name

    CITIZENSHIP: FILIPINO BIRTH DATE: JANUARY 24 1996


    (mm/dd/yy)

    PERMANENT MAILING ADDRESS: MALLANGO EMAIL ADDRESS: janice012496@gmail.com


    SCHOOL GRADUATED:
    KALINGA KALINGA STATE UNIVERSITY
    _________________________________________________________
    TINGLAYAN
    YEAR GRADUATED: April 04 2016
    REGISTRATION DATE: JANUARY 15 2019
    ( mm/dd/yy)
    PROFESSION: Professional
    EXPIRATION DATE: January Teacher
    24 2025
    LICENSE NO: 1724324
    (mm/dd/yy)

    DECLARATION AND ATTESTATION


    I am aware and I give my consent to the collection of the data required by this application form and the
    taking of my photograph, and if applicable, the taking of my fingerprints.
    I further attest that all particulars and supporting documents provided by me are correct and complete.
    I am aware that any false statement or fraudulent document will lead to the rejection of my application or to the
    cancellation of my PIC already issued, a nd may also render me liable under applicable administrative and
    criminal laws.
    SIGNATURE OF LICENSEE
    UNDERTAKING
    (To be filled up by professionals, except for Real Estate Practitioners, who failed to comply with the
    required CPD Credit Units for the renewal of Profess ional Identification Card)
    For this compliance period, I am submitting CPD units of the total required CPD Credit units. I

    hereby undertake to submit the balance of CPD credit units in addition to the required CPD units (or a
    total of units) for the next renewal of my PIC. I understand that in the event I fail to comply, my PIC will not
    be renewed.
    _______________________________
    SIGNATURE OF LICENSEE
    NOTE:
    1) ALL REAL ESTATE PRACTITIONERS CANNOT AVAIL THE UNDERTAKING AND HAVE TO PROVIDE
    PROOF OF COMPLIANCE WITH CPD PRIOR TO RENEWAL OF PIC PURSUANT TO SECTION 17,
    ARTICLE III OF REPUBLIC ACT NO. 9646 OR THE REAL ESTATE SERVICE ACT OF THE
    PHILIPPINES AND BOARD RESOLUTION NO. 49, S. 2015.
    2) REPRESENTATIVE OF THE PROFESSIONAL APPLYING FOR ISSUANCE OF PROFESSIONAL
    IDENTIFICATION CARD (PIC) MUST SUBMIT :
    a) THE PRESCRIBED AUTHORIZATION LETTER AND PHOTOCOPY OF PROFESSIONAL
    IDENTIFICATION CARD (PIC) OF THE REPRESENTATIVE AND EXPIRED PIC OF THE
    PRFESSIONAL; OR
    b) SPECIAL POWER OF ATTORNEY (SPA) AND PHOTOCOPY OF ANY VALID GOVERNMENT
    ISSUED IDENTIFICATION CARD (ID) OF THE REPRESENTATIVE AND THE PROFESSIONAL
    3) STRICTLY FOLLOW THE APPOINTMENT DATE ON RENEWAL OF PROFESSIONAL
    IDENTIFICATION CARD (PIC).
    P HOTO

    9121297683

    ANUARY 24 1996
    mm/dd/yy)

    12496@gmail.com

    04 2016

    nal
    ary Teacher
    24 2025
    mm/dd/yy)

    on form and the

    t and complete.
    plication or to the
    ministrative and

    RE OF LICENSEE

    omply with the

    Credit units. I

    CPD units (or a


    y, my PIC will not

    ______________________
    RE OF LICENSEE
    DE
    7,
    E

    AL

    NAL
    HE

    NT

    NAL

    REG-03
    Rev. 02
    September 15, 2017
    Page 1 of 1

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