REPUBLIC OF THE PHILIPPINES

____________________________
____________________________

AFFIDAVIT OF UNDERTAKING

I, ________________________________ of legal age, married/single and

a resident of _____________________________________________________
after having been duly sworn on oath in accordance with law, do hereby depose
and say:

1) That I am the ______________________________ of

__________________________________________ having been
appointed/designated and authorized by the company to collect
vaccination cards of the employees of
______________________________ and to verify if the employees
of_______________________ is fully vaccinated. Copy of the lists of
the employees who submitted their vaccinations cards is attached
herein as Annex “A”;

2) I, in behalf of ___________________, will hold the Confidential

Personal Information as indicated in the vaccination cards received
from ___________________,______________________ of the
________________________ in strict confidence and will exercise a
reasonable degree of care to prevent disclosure to others.

3) I, in behalf of _____________, will not disclose or divulge either

directly or indirectly the Confidential Personal Information to others
unless first authorized to do so in writing by the employee concerned
and the Company management of
______________________________

4) I, in behalf of ___________________, undertakes to return

immediately the vaccination cards after verification of the vaccination
status of the employees.

I, in behalf of _______________, attest to the truthfulness of this undertaking and hold myself
liable for perjury, falsehood, misrepresentation, or omission if there exist and to be charge for
violation of Republic Act 10173, Data Privacy Act of 2012 in case of breach.

AFFIANT FURTHER SAYETH NONE.

IN TRUTH WHEREOF, I have hereunto sign my name below this ______

day of ________________ at ________________.
 ________________
Affiant

SUBSCRIBED AND SWORN TO before me this ____________ day of

________________ 20____ affiant exhibiting to me his/her
____________________ issued at ________________ on _________________.