REPUBLIC OF THE PHILIPPINES)

BAGUIO CITY. . . . . . .)S.S

AFFIDAVIT OF LOSS
I, XXXX, of legal age, married to XXXXX, with residence and postal address at
XXXXXXXXXXXX, and a regular employee of the Evergreen Shipping Lines
International, with Cargo Safeway as its sole manning agency in the Philippines, after
having been duly sworn to in accordance with law, do hereby depose and state:
hat I have an Identification Card !I"# duly issued by the Professional $egulation
Commission !P$C# as my license for my profession as hird Engineer%
hat I found out the loss of the same when my wallet was lost in &anila,
somewhere in the vicinity of 'ictory Liner Cubao Station after alighting from the bus from
(aguio city%
hat I e)erted all efforts to locate such wallet and all its contents, but to no avail%
hat I have e)erted reasonable efforts to locate the said wallet with my P$C
license I" and all my other Ids with my (PI *& card, but to no avail, hence, I now
declare the said PRC ID LOST;

hat I am e)ecuting this affidavit to attest to the truth of the foregoing facts in
order that I may be issued another P$C license I" to be able to resume my transactions
with public and private agencies concerned%
hat I e)ecute this affidavit of Loss for all legal intents and purposes%
I+ ,I+ESS ,-E$E./, I hereby set my hands and signature this 01
th
day of
*ugust, 2300 at (aguio City, Philippines4
XXXXXXXXXX
CC +o4
Issued at XXX
Issued on
SUBSCRIBED AND SWORN to before me this 19
th
day of August 211 at Baguio City!
affia"t e#hibiti"g to me his Commu"ity $a# Certifi%ate Number i"di%ated be&o' his "ame
a"d sig"ature(
Doc. No. ___
Page No. ___;
Book No.
Sere! o" #$%%