REPUBLIC OF THE PHILIPPINES

CITYOF QUEZON


AFFIDAVIT OF LOSS


I, Carla L. Dela Cruz, Filipino, of legal age and a resident of The Redwoods Condominium, Kaji 210, Pasong Putik
Proper, Novaliches, Quezon City, after having duly sworn to in accordance with the law, hereby depose and say that:

1. Iam a holder of a Certified Physician Identification Card issued by Professional Regulation Commission;

2. I lost said Identification card on May 10, 2014, and that I exerted all my efforts to locate the same but I could
not remember exactly where I placed it and it is considered lost for all legal purposes;

3. Said Identification card was not confiscated by any officer of the law by reason of any violation of any law,
ordinance, presidential decree or rules and regulation of the said Commission; and neither was it offered as
collateral for any loan;

Iam executing this affidavit to attest to the foregoing facts;

IN WITNESS WHEREOF, I have hereunto set my hand this 20
th
of May in the City of Quezon, Philippines.





CARLA L. DELA CRUZ
Affiant


SUBSCRIBED AND SWORD to before me this ______________ in the City of ____________, Philippines,
affiant having exhibited to me his/her community tax certificate with no. ______________________ issued
on ______________ at _________________.


Doc. No:________________
Page No: _______________
Book No:________________
Series of ________________