FM-POEA-06-ESRD-03-b-SRA

Effective May 16, 2012

REPUBLIC OF THE PHILIPPINES )

MANDALUYONG, METRO MANILA ) S.S.

AFFIDAVIT OF UNDERTAKING
I, ______________________________________, of legal age, single/married, Filipino, a resident
of ____________________________________ and with business address at
_________________________________________ after having been subscribed to an oath, depose and
say:

1. That I am the incumbent ______________________________________________________

( position of affiant)
of ___________________________________________, a domestic corporation organized under
( name of agency)
Philippine Laws, and a duly licensed recruitment agency as per License No.
_____________________________ issued by the Philippine Overseas Employment Administration;

2. That as licensed recruitment agency, we requested the POEA to issue in our favor an authority to
conduct recruitment activities in the following provinces/cities on the corresponding dates:
_______________________________________________ _________________________
_______________________________________________ _________________________
_______________________________________________ _________________________

3. That in my capacity as _________________________ of the ________________________

( position of affiant) (name of
__________________________, I hereby DECLARE and ASSUME full responsibility in the orderly
agency)
conduct of recruitment activities of __________________________________________ who has
(name of representative)
been authorized to represent our agency in the recruitment activities in the above-mentioned place/s and
date/s;

4. That I likewise DECLARE and ASSUME full and complete responsibilities for all consequences
which may arise in connection with the conduct of above recruitment activities;

5. That I execute this Affidavit of Undertaking in compliance with the requirements in the issuance
of an authority to conduct special/provincial recruitment activity.

In witness hereof, I hereby set my hand this _____ th day of _________________, 20__, in
_______________________________.

______________________________________
(Affiant)

SUBSCRIBED AND SWORN to before me this __th day of __________________________.

Affiant exhibited to me his/her Residence Cert. No. as indicated above below his name.

NOTARY PUBLIC
Doc. No. ____________
Page No.____________
Book No. ____________
Series of 2012