AFFIDAVIT ON COPYRIGHT CO-OWNERSHIP

REPUBLIC OF THE PHILIPPINES

City of Manila

The undersigned, being duly sworn, do solemnly affirm and say:

1. That he/she is/are the creator/author of the work entitled _____________________

___________________________________________________________________
which is the subject of the application for copyright filed on _____________;

2. That he/she has presented and submitted the said work to the Polytechnic
University of the Philippines as part of the requirements of his/her curricular
program:

3. That upon submission of the work to the Polytechnic University of the Philippines,
he/she acknowledges the University as COPYRIGHT CO-OWNER of the above-
mentioned work; and

4. That as copyright co-owner, PUP has the right to reproduce, publish and publicly
distribute copies of the said work, in whatever form, electronic or otherwise for
instruction purposes, and for any other purposes that promote access to and
utilization of intellectual property of the University; provided that the name of the
author shall be acknowledged/cited in all dissemination and utilization of the work.

In witness whereof, he/she hereunto set his/her signature on this ___ day of ___________,
year ______, in Manila, Philippines.

Author’s/Creator’s Name and Signature:

_________________________________________ _____________________

Subscribed and sworn to or affirmed before me this _____ day of _____________. 2013.

NOTARY PUBLIC
Doc. No.____________
Page No.____________
Book No.___________
Series of ___________