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Examinee Id Sheet Back

The document is an examination application form that collects personal information such as the examinee's school, graduation date, review center, and type of examination. It includes sections for listing subjects for removal examinations and practical exercises. Additionally, it contains a non-disclosure declaration that the examinee must attest to, ensuring confidentiality regarding examination questions.

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Allen Chester
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160 views1 page

Examinee Id Sheet Back

The document is an examination application form that collects personal information such as the examinee's school, graduation date, review center, and type of examination. It includes sections for listing subjects for removal examinations and practical exercises. Additionally, it contains a non-disclosure declaration that the examinee must attest to, ensuring confidentiality regarding examination questions.

Uploaded by

Allen Chester
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DATE OF EXAMINATION

BOARD
OF
SCHOOL GRADUATED FROM LOCATION DATE OF GRADUATION

REVIEW CENTER ATTENDED LOCATION DATE OF BIRTH SEX

TYPE OF EXAMINATION PLACE OF EXAMINATION


COMPLETE THEORY ONLY
MONTH YEAR
REMOVAL PRACTICAL ONLY LAST
EXAMINATION
TAKEN
IN CASE OF REMOVAL EXAMINATION, WRITE THEORETICAL SUBJECT(S) TO BE TAKEN BELOW:

1. 3.

2. 4.

PRACTICAL EXERCISE(S) TO BE TAKEN

1. 2.
PERMANENT MAILING ADDRESS SIGNATURE OVER PRINTED NAME

In your usual handwriting, copy the following paragraphs on the space provided hereunder.
ATTESTATION
ON
NON-DISCLOSURE DECLARATION

I declare upon my oath that I will not take from the examination room any examination questions which
were used in the licensure examination in which I am an examinee, or copy, reproduce and/or divulge or
make know the nature or content of any examination question or answer to any individual or entity and
I will report to the BOARD OF/FOR ___________________________________________________ or the
PROFESSIONAL REGULATION COMMISSION (PRC) anybody who takes or brings out the said examination
questions from the exam room or copy or reproduce the same

I understand that failure on my part to comply with the above undertakings may result in the invalidation
of my grades, disqualification from future examinations and/or may be subjected to criminal prosecution.

Signature of Examinee Administering Officer/Chairman of


(Affiant) Member of the Board

Date:

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