TIME RECEIVED:
TIME RELEASED:
Professional Regulation Commission
APPLICATION FOR PROFESSIONAL IDENTIFICATION CARD (PIC)
NOT FOR SALE (REPRODUCTION IS ALLOWED)
APPOINTMENT DATE: September 06, 2021 (03:00 PM TO 4:00PM) - Festive Walk Mall, Iloilo Business Park
REFERENCE NO: RE1A2D6TP42P | OR: 123207965273 | Amount: PHP 1530.00
NAME: GOMEZ, WILJOHN BRYAN REYES
CITIZENSHIP: FILIPINO BIRTHDATE: September 20, 1988
PERMANENT MAILING ADDRESS: LAGDUNGAN BARANGAY LAGDUNGAN, TAPAZ LAGDUNGAN CAPIZ
TEL. NO. / CP NO.: 09989036839 EMAIL ADDRESS: nayrbgomez@[Link]
SCHOOL GRADUATED: WEST VISAYAS STATE UNIVERSITY-LA PAZ DATE GRADUATED: June 11, 2017
REGISTRATION DATE: September 16, 2008 EXPIRATION DATE: September 20, 2024
PROFESSION: NURSE LICENSE NO.: 0510393
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, and 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 Professional 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).
REG-03
Rev. 02
September 15, 2017
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