ACKNOWLEDGEMENT & UNDERTAKING

This is to acknowledge that I have procured the following products from Pharma Nutria N.A.
(Bacolod City), Inc. with ref SO#_____________ dated _____________________________

NAME OF PRODUCT / PACKING QUANTITY

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10.

I hereby affirm that the above-mentioned pharmaceutical products will not be sold to my
patients nor will be used for financial gain but rather intended for (please check the
appropriate purpose for usage):

___ For Personal Use

___ Charity work, donation to charitable institutions or religious group
___ Use in Medical Mission
___ If others, please specify: _____________________________________________

___________________________
Printed Name & Signature of Doctor

______________________
Date and Place