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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 the 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 of evidence).

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


during the validity of my PIC in addition 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 next 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

SUBSCRIBE 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

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