DECLARATION

I, __________________________________, of legal age, Filipino, and a resident of

___________________________________________ , do hereby say: That-
1. I freely and voluntarily give my testimonial as to the effects on my health and well-being since I
took MX3 products, without being paid, forced, persuaded or influenced in any way by any one,
and that I hereby declare that my statements are true based on what I have experienced;
2. I agree to the use and publication of my personal details, past and present health status, images,
pictures, audio recordings, and videos in MX3 advertisements, publications, and promotions
through any and all forms of media as may be decided solely by the management of MX3 without
need of my additional consent. For the purpose of making my testimonial understandable in any
language or Philippine dialect, I consent to any act for the furtherance of such purpose, such as the
adding of a sub-title, having a voice-over by a different person translate the testimony, and other
acts;
3. That I voluntarily and wholeheartedly gave my consent and support to MX3, and thus I shall not do
any act damaging to MX3, including the withdrawal of my statement, nor shall I campaign for
another herbal supplement in direct or indirect competition with MX3;
4. That I hereby release the makers and manufacturers of MX3, its directors, officers, employees,
agents and representatives, from any and all responsibility and liability in relation to my
consumption and use of MX3 products, as well as in relation to the advertisements, publications,
and promotions of MX3 as stated in paragraph 2;
5. That I will NOT give any similar testimony as to the effects on my health and well-being of any
other products, competitive or not, with the product of MX3, within the period of Two (2) years
from the execution hereof.
6. To ensure compliance with all government laws, I will not make any statement regarding MX3
without written clearance from the officers of MX3 company;
7. That the statements contained herein have been fully explained to me in a language I understand,
and that I execute this document freely, voluntarily, and with whole understanding.
Signed this __________________at ______________ Philippines.

_______________________
Printed Name and Signature

Witnessed by:
_____________________________
Printed Name and Signature

SUBSCRIBED AND SWORN to before me this _____________ at _________________,

personally appeared the above named person with his/her valid document of identity, known to me as the
same person who executed the foregoing instrument and acknowledged the same is their free and
voluntary act and deed.
WITNESS MY HAND AND SEAL, at the place and on the date first above written.

Doc. No. _____

Page No. ____
Book. No. ____
Series of ______.