REPUBLIC OF THE PHILIPPINES)

CITY OF __________________) S.S.

AFFIDAVIT OF UNDERTAKING

I,____________________, Filipino, single/married, a registered and

licensed ___________ (profession), with address at __________________ after
having been duly sworn in accordance with law hereby depose and state that:

1. I applied for the renewal of my Professional Identification Card

(PIC) with the Professional Regulation Commission;

2. As requirement for the renewal of my PIC to date, I have to

submit proof of ___CPD Credit Units in compliance with Republic
Act (RA) No. 10912 or the Continuing Professional Development
Act of 2016, and its Implementing Rules and Regulations (IRR) on
the next renewal of my PIC;

3. Due to ______________________________________________,
(state your reason), I failed to comply with the required CPD
credit units. Attached herein is/are
___________________________(proof or evidence).

4. I undertake to comply with the required ____CPD credit units

during the validity of my PIC in additional to the required
_____CPD Credit Units for the subsequent renewal period;

5. I will submit proof of my compliance with ____total number of

CPD Credit Units during the next renewal of my PIC:

6. I understand that in the event I fail to submit compliance with the

required total number of CPD Credit Units, I cannot renew my PIC
on the nest succeeding renewal periods;

7. I am executing this affidavit to attest to the truth and veracity of

the foregoing statements for whatever legal purpose it may
serve;

8. AFFIANTS FURTHER SAYETH NAUGHT.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this __ day of ______2017, at

___________, Philippines, affiant exhibiting to me his/her
________________(valid issued government Identification Card) issued on
__________ at ___________.

Doc. No._______
Page No._______
Book No._______
Series of 2017