Annex "A"

Letter Head of the Institution/Agency/Entity

(with address and contact details)

CERTIFICATION

I, ____________, (designation), officer of institution/agency/entity do certify that

__________________, an employee/official/resident/consultant/volunteer herein was assigned /
provided outstanding services, as ________________ at ______(place)__________________ from
____(period)_____________ during the State of Public Health Emergency brought about by the Corona
Virus Disease 2019 (COVID-19)

As such, he/she (details of functions/ tasks/accomplishment/)

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________________________________________________.

This is issued for his/her Continuing Professional Development compliance application and other
legal purposes it may serve.

This ____ day of ______________ at _____________________.

________________________

Signature over printed name

(Designation)

SUBSCRIBED and sworn to before me, a Notary Public for _______________, Affiant exhibiting
before me his/her government issued identification card __________, issued at ________________ on
___________________.

This _____ day of ___________ at ____________________.

Notary Public

Doc. No

Page No.

Book No.

Series of