REPUBLIC OF THE PHILIPPINES)

CITY/MUNICIPALITY OF ___________)S.S.

(AFFIDAVIT OF ASSUMPTION OF RESPONSIBILITY)

AND MASTERLIST OF EMPLOYEES

I, Racquel G. Francisco in my capacity as Logistics Supervisor

with address at Daan na Cruz, Maasim, San Rafael
that the name/s appearing in the herein masterlist is/are my bonafide employee/s.

NAME POSITION/DESIGNATION SIGNATURE

1. Racquel G. Francisco Logistics Supervisor
----- nothing follows ------

That the above named employees are duly authorized to transact business for and in my behalf at PMO
NCR North and binds myself to be liable for whatever damages said employee/s may cause when
representing me.

That this Affidavit is executed in connection with this application for PPA ANNUAL Port User's Pass subject to
existing Port Rules and Regulations.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ______ Day of ________________ at
______________________________ Philippines.

Racquel G. Francisco
Affiant

SUBSCRIBED AND SWORN to before me this _______ day of _____________ 20_____ the herein
affiant exhibiting his/her Community Tax Certificate No. issued at
________________________, Philippines on _______________, 20_______.

(Notary Public)

Doc. No.__________
Page No._________
Book No._________
Series of_________