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REPUBLIC OF THE PHILIPPINES)

City of Puerto Princesa ) S.S.

x-----------------------x

AFFIDAVIT OF LOSS

I, JOSEPH D. DAJAY, of legal age, Filipino, married, and a resident of Barangay


Sta. Monica, Puerto Princesa City., Philippines, after having been duly sworn in
accordance with law, hereby depose and state:

1. That I was issued a Professional Identification Card/License by the


Professional Regulation Commission as Medical Technologist with
Registration No. 020419 which will expire on May 1, 2016;
.
2. That recently when I was trying to cash a check with a bank and a valid
identification card was required, but the same could not be found inside my
wallet;

3. That despite diligent search and efforts to locate the said Professional
Identification Card,, I could not find the same such that I now believe that it is
now lost beyond recovery;

4. As such, I am executing this Affidavit of Loss to attest to the truth of the


foregoing and to support the application for the issuance of new one in lieu of
the one which was lost.

IN WITNESS WHEREOF, I have hereunto set my hand this ____________at


Puerto Princesa, Philippines.

JOSEPH D. DAJAY
Affiant

SUBSCRIBED AND SWORN to before me this _____________ at Puerto


Princesa City. Affiant exhibiting to me his Community Tax Certificate No. 26064501,
issued on February 20, 2015, at Puerto Princesa City to be the same person who
executed this affidavit.

NOTARY PUBLIC

Doc. No. ______;


Page No. ______;
Book No. ______;
Series of 2015;