REPUBLIC OF THE PHILIPPINES

CITY OF BACOLOD

AFFIDAVIT
I, ____________________, of legal age, single, Filipino and a resident of
_________________________, , after being duly sworn in accordance with the law,
depose and say:

1. That I was employed by CORAZON LOCSIN MONTELIBANO MEMORIAL

REGIONAL HOSPITAL (CLMMRH) as Staff Nurse from November 1, 2004
to August 5, 2014;

2. That my employment with CLMMRH is supported by the Certification issued

in my favor, to wit:

a) CERTIFICATION issued by CORAZON LOCSIN MONTELIBANO

MEMORIAL REGIONAL HOSPITAL dated November 13, 2019
certifying to the fact of my employment as Staff Nurse from
November 1, 2004 to August 5, 2014, signed by LUCIA D.
ALARBA, JORESLYN P. BALA-AN and DR. JULIUS M. DRILON;

3. That the above-mentioned Certificate was issued in my name and by a person

authorized to issue the same;

4. That the said certificate is genuine and a faithful reproduction of the original
document on record;

5. That I am executing this affidavit to attest the truth of the foregoing facts and
for whatever legal purpose this may serve.

IN WITNESS WHEREOF, we have hereunto set our hand this _______ day of
_________, in the City of ________, Philippines.

______________________________

AFFIANT

SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for the City
of Bacolod, this 22nd day of November 2019. Affiant personally came and appeared with
her Identification Card (_________) bearing her photograph and signature, known to
me as the same person who personally signed the foregoing instrument before me and
avowed under penalty of law to the whole truth of the contents of said instrument.

Doc No. _______;

Page No. _______;
Book No. _______;
Series of 2019.