REPUBLIC OF THE PHILIPPINES )

ILOCOS NORTE ) Sc.

AFFIDAVIT OF UNDERTAKING

I, ________________________, of legal age and resident of ____________________

_________________________ after having been duly sworn according to law, hereby depose
and state that:

1. I am a resident of _____________________ and declare that I am an authorized

person outside residence (APOR);

2. To the best of my knowledge, I am not infected with COVID-19;

3. I am an employee of ___________________________, occupying the position of

_________________________;

4. The agency to which I work, is at full operational capacity, thus I’m required to
discharge the duties and functions of my office and is required to be physically
present in order to deliver the office’s mandate;

5. As I enter the Province of Ilocos Norte, and by virtue of this affidavit, I undertake to:

a. Agree to undergo comprehensive health check by staff from Provincial Health

Office upon the arrival at the provincial boarder at Municipality of Badoc, Ilocos
Norte;
b. Present Identification card and other documents to show the nature of work;
c. Submit proof/s of residency;
d. To divulge the name, contact number, company, company contact name and
number, and the duration of stay in Ilocos Norte;
e. Undergo decontamination process by Bureau of Fire Protection (BFP); and
f. Agree to limit stay at the assigned work place, shall not roam around elsewhere
within 14 days from entry and comply with the strict protocols;

6. I am executing this affidavit as my voluntary act and deed for whatever legal intents
and purposes it may be worth.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ____________

at _________________.

___________________________
affiant
I.D. No. ________________

SUBSCRIBED AND SWORN TO before me this ___ day of _________ 2020. That I
have examined the affiant and s/he declared to me that s/he had read and understood the
foregoing, his/her voluntary act and deed and that the same are true to the best of his/her
knowledge and based on authentic records.

Doc. ______;
Page ______;
Book ______;
Series of 2020.