SWORN DECLARATION of PERSONALLY TAKING A J3TCI ONLINE COURSE

I, Shenley Rose Lucinario, Filipino, of legal age, single/married, permanently residing at 3 Dona
Pacita St. Old Balara Quezon City, and working at Socera M. Lucinario Construction with address
at 41B Dadison st. Brgy 56 Pericohon, Tacloban City.
after having been sworn in accordance with law hereby depose and declare that:

• I have personally taken the online course at the J3 Trainers and Consultants online
training platform:

/ / COSH (40-HOURS)

• I have taken the quizzes and final examination without help from others.

• I duly execute this SWORN DECLARATION in compliance with the requirement issued by
the Occupational Safety and Health Center of the Department of Labor and Employment
(DOLE) as proof that the course was personally taken by me and the examinations
without help from others.

• I declare under penalty of perjury, that this declaration has been made in good faith and
to the best of my knowledge and belief to be true and correct.

IN WITNESS WHEREOF, I have unto set my hand this 30th day of May, 2022 at Quezon City.

___________________________________
(Signature over printed name of enrollee)

SUBSCRIBED AND SWORN to before me this ______ day of ______________________, 20____

in ________________________________________________, Enrollee exhibited to me his/her
_______________________________ issued at at ___________________ on ______________.

Doc. No. _______

Page No. _______
Book No. _______
Series of _______