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PRC Form No. 104 (Revised February 2000)
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COMPANY / OFFICE NAME
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ADDRESS
CERTIFICATE OF EXPERIENCE
WARNING : All statements are subject to verification and any false statement or misrepresentation made in this CERTIFICATE OF EXPERIENCE is a ground for disqualification and criminal prosecution for falsification.
TO THE BOARD OF MECHANICAL ENGINEERING
I HEREBY CERTIFY THAT Mr. NAME OF APPLICANT has worked with COMPANY NAME located at COMPANY ADDRESS as follows: COMPANY / 0FFICE NAME
|FROM |TO |POSITION HELD |SPECIFIC NATURE OF WORK AND RESPONSIBILITIES |
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This is to certify further that Mr. NAME OF APPLICANT has actually performed the duties enumerated above under my direct supervision being a registered Professional Mechanical Engineer with Registration Number 03305 dated June 2, 1998, and that my professional license is valid and will expire on June 26, 2011.
Dated on ______________ at ____________.
JEFFREY F. SINGSON
Affiant (Certifying Officer)
SUBSCRIBED AND SWORN BEFORE ME this ___________ day of _________ at ___________. Affiant exhibited to me his Community Tax Certificate No. _____________ issued on ___________ at _______________.
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Notary Public
IMPORTANT : 1. The supervisor must be a registered and currently licensed professional.
2. This form is good only for one supervisor. Use another sheet for experience/s under other supervisor/s
3. Certificate of Employment must accompany this Certificate of Experience.
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