REPUBLIC OF THE PHILIPPINES )

AFFIDAVIT OF LOSS

I, Maita Janina Bartilad, Filipino, of legal age, single and a resident of Unit 5, 406
Fleurdeliz St., Greenheights Newtown, Brgy. Mayamot, Antipolo City, Philippines, after
having duly sworn to in accordance with law, hereby depose and say that:

I am a holder of a Certified Nursing Identification Card issued by Professional

Regulation Commission;

I lost said Identification Card on November 7,2016 and that I exerted all efforts to
locate the same but I could not remember exactly where I placed it and it is considered
lost for all legal purposes;

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; andneither was it offered as collateral for any loan;

I am executing this affidavit to attest to the foregoing facts;

IN WITNESS WHEREOF, I have hereunto set my hand this 13th of May in the City of
Quezon, Philippines.

ADRIAN P. MANGAOANG

Affiant

SUBSCRIBED AND SWORN to before me, this ____ day of _____, 20___ in
___________________ City, with affiant exhibiting his CTC No. _______________ ,
Issued on ______________________ at _________________________.

NOTARY PUBLIC
Until December 31, 20___

Doc. No. : ________;

Page No. : ________;
Book No. : ________;
Series of 20___.