REPUBLIC OF THE PHILIPPINES

Province of Negros Occidental) S.S.

City of Bacolod)

AFFIDAVIT

I, EUSEBIO T. MANA-AY, of legal age, single, Filipino, with residence at Bago

City, Negros Occidental, after having been duly sworn to in accordance with law, do
hereby depose and state the following:

1. That I was issued by the Department of Trade and Industry (DTI) a

certificate of Business Name Registration under the name ACM
DIAGNOSTIC LABORATORY AND MEDICAL CLINIC which was issued
_____________ in Bacolod City, Philippines;

2. That the registration of ACM DIAGNOSTIC LABORATORY AND MEDICAL

CLINIC was renewed with DTI on ______________;

3. That I submitted a Quotation with the City Government of Bago for the
Drug Testing of its Three Hundred (300) employees;

4. That in the said quotation, the name ACM DIAGNOSTIC DRUG TESTING
CENTER was placed instead of the registered name ACM DIAGNOSTIC
LABORATORY AND MEDICAL CLINIC;

5. That the business name ACM DIAGNOSTIC DRUG TESTING CENTER is the
same with ACM DIAGNOSTIC LABORATORY AND MEDICAL CLINIC, the
latter being the true and correct business name;

6. That the discrepancy in the name as appearing in the Quotation submitted

with the City Government of Bago was due to inadvertence and excusable
neglect, and was not in any way intended to defraud or prejudice the rights
of any person;

7. That I am executing this affidavit to attest to the truth of the foregoing and
for whatever legal purposes that this statement may serve.

IN WITNESS WHEREOF, I have hereunto set my hands this _____ day of

_____________, 2018, in the City of Bacolod, Philippines.

EUSEBIO T. MANA-AY
AFFIANT

SUBSCRIBED AND SWORN to before me, this _____ day of ______________,

2018, by DENNIS S. GUMABONG, who exhibited to me his PRC ID (Reg. No. D1-
0035496) issued at Bacolod City, Philippines.
Doc No. _______
Page No. _______
Book No. _______
Series of 2018