AFFIDAVIT OF UNDERTAKING

I ___________________________________, of legal age, single/married, Filipino citizen with

business located at _________________________________________________ under oath, hereby
depose and state THAT;

1. I am the owner/manager/ legal representative of (name of establishment)

______________________________________________________, with principal address at
______________________________________________________________________;
2. In connection with my application for Mayor’s/Business Permit, I do hereby UNDERTAKE
to:

STRICTLY COMPLY WITH CITY ORDINANCE NO. 2022-1033, ENTITLED, “AN ORDINANCE
BANNING THE SALE, DISPENSATION AND RESALE OF PHARMACUETICAL PRODUCTS IN
SARI-SARI STORES AND OTHER SIMILAR RETAIL OUTLETS, PROHIBITNG THE SALE,
MANUFACTURE AND POSSESSION OF COUNTERFEIT DRUGS IN THE CITY OF ANTIPOLO,
PROVIDING PENALTIES FOR VIOLATION THEREOF AND FOR OTHER PURPOSES”.

3. Failing which I understand and admit that my eligibility and application including permit
obtained hereto stands to be automatically cancelled and/or revoked at the option of the
City Government of Antipolo and the latter is not to be held responsible for the same.

4. I am executing this statement to attest to the truth of the foregoing and for whatever lawful
purpose this may serve.

IN WITNESS WHEREOF, I hereby set our hands this _____ of day _____ in ___________________

_________________________________________
PRINT NAME AND SIGN/DESIGNATION

SUBSCRIBED AND SWORN to before me, this ______ of day _______ in

_____________________.

NOTARY PUBLIC

Doc. No. :______

Page No. :______
Book No.:______
Series of 202__.