Republic of the Philippines)

_________________________ ) S.S.

AFFIDAVIT OF DECLARATION

MARY JOY DEVEDE DELEON

That I________________________________, of legal age, single/married, Filipino citizen,
SITIO PUGAD LAWIN ALMANZA DOS, LAS PIÑAS CITY
with residence and postal address at ___________________________________________________,
after having been duly sworn to in accordance with law, hereby depose and say:

PRUDENTIAL EMPLOYMENT AGENCY INC.

1. That I am an applicant of ____________________________________________________________
JAPAN
for the position of ______________________________________for_________________________;
YOUR CATEGORY

2. That in support of my application, I have submitted to the said agency the following documents, to
wit;
Credentials of Sending Company:
_____ Bio-data ______ Passport
_____ DTI/ SEC/CDA Certificate of
_____ PSA Birth Certificate Credentials of Sending Company:
Registration
_____ High School/College Diploma _____ Company
______ DTI/SEC/CDA
Profile Certificate of
_____ NBI Clearance ______ Duly Accomplished OTIT Forms
Registration
_____ Medical Certificate ______
_____ 1-28Company
CertificateProfile
issued by the Organization
of Affiliation in a Foreign Country
_____ LCR Copy of Birth Certificate _____ Duly Accomplished OTIT
______ 1-10 (Curriculum Vitae)
JITCO Forms
_____ PSA Marriage Contract _____ Certificate
______ Certificate of Employment
of Employment
_____ Employment Certificate _____ Agreement
______ Pictures of Sending
OTHERSBetween Company
Trainee and PEA
_____ Certificate of Residency _____ Others
______ Others
_____
______ Agreement Between Trainee and
Passport
PEA

3. That the aforementioned documents were personally obtained by me and I hereby undertake
and guarantee that the same are genuine and authentic;

4. That any false or erroneous information, misrepresentation, misstatement and irregularity of

said documents are my sole responsibility and not that of the agency;

5. That I declare and state that I am relieving and absolving said agency, including its officers
and employees, from any liability, civil, criminal, and administrative that may arise in relation
to the aforementioned documents.

6. That I further undertake not to get pregnant from the time of acceptance of the Japanese
Employer to the commencement of my Nihongo language training until the expiration of my
Three (3) Years employment contract;

7. That should I fail to finish my employment contract by reason of my pregnancy, I will

reimburse my local agency and foreign employer for the expenses they incurred pursuant to
my deployment abroad without prejudice to the institution of appropriate Disciplinary Action
against Worker before the Philippine Overseas Employment Administration (POEA);
 IN WITNESS WHEREOF, I have hereunto signed this Affidavit of Declaration on
this ____day of ____________, 2017
2019 at ______________________, Philippines.
2022

___________________________
Affiant
Witness:

_____________________

SUBSCRIBED AND SWORN, to before me this___ day of______, 2017.

2019 Affiant
2022
exhibited to me his/her Passport No___________issued on______________ at
____________.

Notary Public
Doc. No._______
Page No._______
Book No._______
Series of 2017.
2019.
2022.