REPUBLIC OF THE PHILIPPINES]

CITY OF __________________ ] S.S.

A F F I D AV I T O F LO SS

I, _______________________________, of legal age, Filipino citizen and a resident

of ____________________________________________, Philippines, after having been duly
sworn to in accordance with law, hereby depose and state:

That I am presently working with Globe Telecom( )/Globe Exchange, Inc.( ),

as a/an (indicate position/band) ___________________________:

That in connection therewith, I was issued a

- Company Identification Card with Employee No. __________

- Temporary Employee Pass with Card No. __________;

Nature of Incident:
That on or
about: (Time) (Day) (Month) (Year)

(Give brief description of incident)

_________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________.

That said COMPANY ID/TEMPORARY EMPLOYEE PASS was lost and despite
diligent efforts exerted to locate the same, it could no longer be found.

This Affidavit of Loss is executed in order to establish the foregoing fact of

loss and to request the aforestated Company to issue a new Identification Card in
lieu of the lost one.

In WITNESS WHEREOF, I have hereunto affixed my signature this _____ day

of ___________________ in the City of __________________, Philippines.

Affiant

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

____________________, Philippines, after affiant exhibited to me Community Tax
Certificate No. _______________ issued on _______________ at ____________________,
Philippines.

NOTARY PUBLIC

Doc. No. _________

Page No. _________
Book No. _________
Series of _________

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