DOE FORM – UNDERTAKING OIMB/COR#022-COCDrev1

AFFIDAVIT OF UNDERTAKING FOR CERTIFICATE OF COMPLIANCE

I, ______________________________________________________ with residential address at

(Name)
______________________________________________ under oath, hereby depose and state THAT;
(Address)

1. I am the owner/authorized representative of ___________________________________,

(Business Name)
as authorized under Board Resolution No. _____________ dated _____________ with DTI/SEC/CDA
Registration No. _____________, Business Permit No. _____________ and office address at
______________________________________________________________;
(Business Address)

2. Pursuant to Section 6(b) of Department Circular No. 2017-11-0011, otherwise known as

the “Revised Retail Rules,” I hereby commit to comply with all the requirements provided
for by said circular for a Certificate of Compliance (COC);

3. My non-compliance with the above duties/responsibilities shall give the Department of

Energy the right not to proceed with my application;

4. I have read the contents and the facts stated herein are true and correct based on my
personal knowledge;

5. I likewise UNDERTAKE and ASSUME full and complete responsibility for all consequences
which may arise in connection with said registration/application; and

6. I am executing this affidavit in compliance with the requirements for the issuance of COC
pursuant to the said department circular.

IN WITNESS WHEREOF, I hereby set my hand this _______of day __________________ in

________________________________.

______________________________
Affiant

SUBSCRIBED AND SWORN to before me this ____ day of ___________ at _____________.

Affiant having exhibited to me his/her____________________________ issued at _______________
(Government ID)
on _________________.

Doc. No.: ________

Page No.: ________ NOTARY PUBLIC
Book No.: ________
Series of _________