REPUBLIC OF THE PHILIPPINES) GENERAL TINIO! NES ss 4 Wwe soto inna, of Negatage, single maid to residing 8722 epuisory OKO LING Tio VEYA TH after having teen ty sworn to accordance wh ia, 60 Nereoy Bepost 20 Sr: L_ That thave never been approached by any employee of the Phitppine Overseas Employment Administration (POE, ot of indesial Persomel and Managetnat Serdces in. (PAMS) ond ached to gay any Placement Fee or mate any ‘contribution forthe senices rendered t mein obtaining job overseasas CAN OTRENDANT with QATAR Awa 2. That id not make any payment oF contribution in whatever form to any person acing 25 recrulter oF agent of {PAMS,orim any other capaci tor serves fendered ta me ® aw aplication fr the abowe mentioned jb overseas; 2. That nthe event tad ny application le procesting ln progress, agree to eimbrse IPAMS the actual “and admintranve Cont: pertaming to ty application for employment a per attached “Offer of Employment” and “Schedule of Administrative rorges fr Withdrawing Candidate” forms! sted: (Amex A) 4. That have not been imalved, charged or have committed any offense, creinal, hl or administrative, nor have ‘oxen apprehended by police authorities, or Nin the Phiippines, of equnatont authorities i foreign counties, or have ‘been incarcerated, fr fearon’ may be refuse entry to start employment in the country where wil be deployed, 5. That did not provide or sibat fats information or documents for purposes ofthis job application which i an ‘ctlense and 2 ground for dsciptinary action against Overseas Workers under Part Vil Rule Wl of 2002 POEA Rules and ‘Regulations gomerning the Recruitment and Employment of Land-bascd Overseas Workers 2s Revised in 2016. & __Thatidpnothave any pending case avohing monetary accountabies with my forme emoloyersin the Philipines andi foreign countries where hove worked before and am not under the POEA watchst either have 2 pending se at ‘he POEAoF the National Labor Relations Commission (NLRC) 7. Thatin the event am denied vss / refused entry into the country where willbe employe, for misepresentation non-disclosure of significant events regarding my prewous local or overses employment o any reason of ntruthviness ofthe foregoing Statement, | wil not hold IPAMS and/or QATAR AIRWAYS Bale for my repatriation, and that | shall reimburse and pay al costs incurred by AMS and/or QATAR AIRWAYS fr my mobilization and repatriation, inching applicable darnages and penatie: 2: may be imposed by the Pancnal/Employe nd wll net fe any complaint oF dai whatsoever asa rest thereat; That for maried candidates), my spouse i fully aware anc has personal knowtedige that! have siged an Offer of [Employment and “Schedule of Adminitratwe Charges for Withdrawing Condiate” 2: mentioned above fn em 3, and that he/she has no objection whatsoever to my joining the company for overseas employment: ‘3. That Lam voluntary ad witty executing this Aout, free from duress, threat or ietimidation. ML WITNESS WHEREOF, 1 have hereunto Set my hand this 72 _ day of JUNE _2927'm the Gry of NUEVA 2O15A ehaippines. : wets = contone by Spouse: JO) ax carn; is 7 "Signature over Printed Name) svexnecomosworroncrene ned 2 Ai 2022 a5 ffant exibaing to me hisfher Passport Mo. med at Doct. Page No. Book No. series of MN. ATTY. B. BACT( Ni PUBLIC. & UNTILYUNE 30, 2022 ee ATTORNEY'S ROLL NO. 74375 PTR NO.'7349688 1/1/2022 IBP No. 157636; 02/16/2021 NOTARIAL COMMISSION 07/20 GAPAN CITY, NUEVA ECIJA