Republic of the Philippines
Professional Regulation Commission
Manila
PETITION FOR CHANGE OF REGISTERED NAME DUE TO MARRIAGE
(Please see reverse side on Requirements and Procedures)
I, ____________________________________________________ of legal age, married, born
(name)
on ___________________ at _______________________________________________ and a resident of
(date of birth)
(place of birth)
____________________________________________________, do hereby apply for change of name
(permanent mailing address)
from _______________________________________ to _______________________________________
(registered name)
(married name)
in the records_____________________________________ of the Board of/for
__________________________________ and the Commission.
(name of board)
I took and passed the examination given by the Board in _________________________ and was
(month & year)
registered as _____________________ with Registration number ____________ dated ______________
and I got married to _____________________________________ at _____________________________
(husband’s name)
(place of marriage)
on _________________________ .
(date of marriage)
(A copy of Marriage Contract/Certificate of Marriage is herewith attached as Annex “A”)
I DO HEREBY CERTIFY that the foregoing date and those in the attached Marriage
Contract/Certificate of Marriage, are all true and correct of my own knowledge, and that any false
declaration herein and in the annex shall hold me liable for criminal/administrative prosecution.
Date Accomplished
Signature (Maiden Name)
Signature (Married Name)
Affix Doc Stamp
HERE
Administering Officer:
(1) REGISTRATION
DIVISION
Window
(DO NOT FILL THIS PORTION)
V e r i f i c a t i o n
(2) RECORDS SECTION
(Annex Bldg.)
Registered Name
Name in the Master Li