REPUBLICOFTHEPHILIPPINES)

LegazpiCity)ss.
xx
A ffi d a v i t
I, _____________________________, Filipino, of legal age, single and a resident of
__________________________Philippinesafterhavingdulysworninaccordancewiththelaw,
herebydeposeandsaythat;

1. ThatIamaRegisteredNursewithProf.IdentificationCardNo:0744532issued
bytheProfessionalRegulationCommission(PRC);

2. That I am the subject person in the following certifications mentioned

below:

i. CERTIFICATION issued by the Bicol Regional Training Teaching

Hospital(BRTTH);
ii. CERTIFICATION issued by the Masbate Medical Mission Group
Hospital Service Cooperative operating and managing Masbate
DoctorsHospital;

2. That I am the one who caused the authentication of the said documents
beforeaNotaryPublicofAlbayandwithinthejurisdictionoftheRegional
TrialCourtofLegazpiCity,Albay;

3. ThatIguaranteetheauthenticityandgenuinenessofthesaiddocuments;

4. That I shall be responsible and liable for the submitted documents if the
same is found spurious or tampered upon verification, validation and
authenticationbyanyprivateorgovernmentoffices/s;

5. That this affidavit is executed to attest to the truth of the foregoing

statementandforwhateverlegalpurposeitmayserve;

Furtheraffiantsayethnaught.

___________________________
Affiant
CompetentIDNo.__________________

SUBSCRIBED AND SWORN TO before me this ___________________ at

_____________,andpresentedtheforegoingAFFIDAVIT.Affiantfurtherexhibitedto
metohercompetentproofofidentitythroughthedocumentwrittenbelowhername,
pursuanttoRule2,Sec.12(a)ofthe2004RulesonNotarialPractice.

Doc.No._____;
PageNo.___;
BookNo.___;
Seriesof2016.