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TO BE ACCOMPLISHED PRC REG Form No. 003 (Rev.

01/2006)
PERSONALLY BY THE Republic of the Philippines
PROFESSIONAL
Professional Regulation Commission
RENEWAL Lucena City
DUPLICATE Paste here
REPRINT REGISTRATION DIVISION
your recent
PASSPORT SIZE
CHANGE OF NAME colored picture with
CHANGE OF DATE OF BIRTH APPLICATION FOR PROFESSIONAL IDENTIFICATION CARD complete name tag in
PLS. PRINT LEGIBLY plain white background

Last Name First Name Middle Name


PERMANENT MAILING ADDDRESS:
DATE FILED: PROFESSION: EXAM DATE:
REGISTRATION DATE: LICENSE / REGISTRATION NO: EXPIRATION DATE:
(mm/dd/yyyy)
CITIZENSHIP: BIRTH DATE: CONTACT NO:
(mm/dd/yyyy)
This is to certify that the above information are true and correct
Signature of Licensee
FOR PRC PROCESSING

YLP FROM: TO: P AMOUNT: O.R. NO.:


SURCHARGE:
TOTAL AMOUNT: DATE: ISSUED BY:
VERIFIED AND ASSESSED BY:

PRC-LUCENA CLAIM SLIP (to be filled up by the applicant)


ISSUED BY: __________________________________________ DATE FILED: _________________________
NAME: DATE OF BIRTH: AMOUNT:
PROFESSION: OR NO.:
REGISTRATION NO.: REGISTRATION DATE: DATE PAID:
APPLICATION TYPE: RENEWAL DUPLICATE REPRINT CHANGE OF STATUS CORRECTION OF DATE OF BIRTH/NAME
Please present this slip to claim your professional ID on _________________________ at Window _______.
(NOTE: AUTHORIZED REPRESENTATIVE WHO IS NON-PRC LICENSE HOLDER SHOULD PRESENT SPECIAL POWER OF ATTORNEY FROM
THE REGISTERED PROFESSIONAL AND THIS ORIGINAL CLAIM SLIP. AUTHORIZED REPRESENTATIVE WHO HOLDS A VALID PRC ID SHALL
ONLY PRESENT AUTHORIZATION LETTER AND THIS ORIGINAL CLAIM SLIP). (042) 373-7316
PROCEDURES

Step 1 Present duly accomplished form together with the requirements at the designated window
for assessment.
Step 2 Pay prescribed fee at the Cashier (Window 17)
Step 3 Submit this form and get your claim slip at the following profession counters:
Window 2 - UNIT C; Window 3 - UNIT B; Window 7 - UNIT A
Step 4 Claim your professional license as scheduled. Please refer to your claim slip for further
instruction.

REQUIREMENTS

1. Duly accomplished form.


2. Two (2) pcs passport sized picture: close up, colored, plain white background with complete
name tag (last name, first name, middle name).
3. Recent professional ID card.
4. In case of LOST professional ID card which is still current, the applicant shall submit notarized
Affidavit of Loss.
5. In case of DESTROYED professional ID card, the applicant shall surrender the destroyed card.

NOTE: As the authorized representative. I assume direct and full


responsibility/liability for the security of the professional ID.


____________________________________________________
Signature over Printed Name of Representative/Profession/License No.

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