Affidavit of Undertaking for Renewal of License to Operate a DOH Hospital

Name of Hospital Complete Address No. & Street City/Municipality Region Telephone and/or Fax Number Chief of Hospital/Medical Director Authorized Bed Capacity Ancillary and Other Clinical Services: [ ] Clinical Laboratory [ ] Primary [ ] Secondary [ ] Tertiary [ ] Blood Bank [ ] Blood Collection Unit [ ] Blood Station [ ] HIV Testing Laboratory [ ] Laboratory for Drinking Water Analysis [ ] Pharmacy [ ] No. of satellite, specify [ ] Dialysis Clinic [ ] Others, specify : :

: : :

[ ] X-ray Service [ ] Level 1 [ ] Level 2 [ ] Level 3 [ ] Specialized Service [ ] Computed Tomography [ ] Mammography [ ] Cardiac Catheterization [ ] Digital Subtraction Angiography [ ] Angiography [ ] Bone Densitometry [ ] Dental [ ] Panoramic [ ] Cephalometric [ ] Others, specify

REPUBLIC OF THE PHILIPPINES ) CITY/ MUNICIPALITY OF _______________) S.S.

I, ____________________________, ____________________________, of legal age, ______________, a Name Designation Civil Status resident of __________________________________________________, after having been sworn in accordance with law Home Address hereby depose and say that I am executing this affidavit to attest to the hospitals continuous compliance with all standards and requirements for the Renewal of License to Operate a ______________ Hospital as set by the Department of Health. Service Capability

_________________________ Signature Before me, this _______ day of ______________ 2007 in the City/ Municipality of _____________________, Philippines, personally appeared the above affiant with Community Tax Certificate No. _____________________ issued on _____________________ at _____________________, known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is their free act and deed. IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2007.

NOTARY PUBLIC My Commission Expires December 31, 20______ Doc. No. ________________; Page No. ________________; Book No. ________________; Series of 20______________

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