Acknowledgement REPUBLIC OF THE PHILIPPINES ) CITY/ MUNICIPALITY OF Sn gan daty) S-S- |, MA. ALMA P. BERNARDO, MD_, MARRIED , of legal age, _45 _, a resident Name: Cha Satu ‘foe ‘of LORETO AGUSAN DELSUR___. after having been swom in accordance with ‘Ascroas law hereby depose and say that | am executing this affidavit to attest to the completeness and truth of the foregoing information for the Registration of Patient Transport Vehicles in the Philippines pursuant to Administrative Order No. 2018-0001 “Revised Rules and Regulations Governing the Licensure of Land Ambulances and Ambulance Service Providers.” a ‘Sighature Before me, this _9""_ day of AUGUST __ 2023 _ in the City/Municipality of LORETO AGUSAN DELSUR_, Philippines, personally appeared the above affiant with Community Tax Certificate No, _27575761. issued on 91/05/2023 at LORETOAGUSANDELSUR Known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same is their free act and deed. IN WITNESS WHEREOF, | have hereunto set my hands this Avo 10 423 day of o_o Eon PageNo. AITY. P oe Book No. __ couwissionyy UNTIL DECERBIFES 2024 Series of _% ‘wp LireTINE 08 PTRND O19 /O1%0- 025 SS MELE cuW AD Wibestag 5/03 \3-eu28 futipuroee-7.* sau ROLL NO. 49383Republic of the Philippines ANNEX A Department of Health HEALTH FACILITIES AND SERVICES REGULATORY BUREAU REGISTRATION OF PATIENT TRANSPORT VEHICLE (PTV) ‘Owner of Vehicle: PROVINCE OF AGUSAN DEL SUR (@5 reflected in the Land Transportation Office (LTO) Registration) Complete Address: PATIN-AY, No. & Street Barangay PROSPERIDAD [AGUSAN DEL SUR 3B ity] Municipality Province Region Tel. /Fax. No.: Mobile No.:_09176355436 E-mail Address: _loretodistricthospital@gmail.com |. Classification: A. According to institutional Character: Institution-Based: PTVs owned by Health Facilities regulated by the Department of Health (DOH), tick (~) appropriate box: ‘CO Hospital General: ClLevel1 ClLevel2 Ci Level 3 Specialty, please specify. O Infirmary Birthing Home ‘Others, please specify, Non-institution-Basedi Free-Standit PTVs not owned by Health Facilties regulated by the DOH, tick (v) appropriate box: i Provincial Health Office Cl Rural Health Unit 1D Municipal Health Office O Barangay Health Station O City Health Office Health Center Others, please specify. B. According to Ownership: Government O Private |, No. of Vehicles for Registration: List down the LTO Certificate of Registration and Plate Number or Conduction Sticker ‘Number per vehicle applied for registration: Vehicle | LTO Certicate of Registration | Eats Kinser 7 Corxkaion 4 asisaias-6 + - B6P288 = 2 I — Saget 2