Republic of the Philippines)

City of Davao ---------------)ss

AFFIDAVIT OF LOSS

I, JAREN CAUILAN VILLAROZA, of legal age, single, Filipino and with postal
address at Poblacion, Tupi, South Cotabato, after having been duly sworn to in
accordance with law, hereby depose and state:

1. That I am a duly licensed professional nurse having passed the Board

Examination for Nursing in 2008;

2. That I was issued my PRC License in 2008, Registration No. 0559149 and
expired on September 2011;

3. That I applied for renewal with the Professional Regulation Commission on

September 21, 2015 but my PRC License ID has not yet been issued up to
the present;

4. That when I followed up my license, I could no longer locate the claim stub
that was issued to me and despite deligent efforts I failed to locate the
same and I know that it was already lost and could no longer be recovered;

5. That I am executing this Affidavit to inform PRC that the claim stub issued
to me to claim my PRC License was lost and never recovered and for the
purpose of getting my PRC License despite loss of my claim stub.

In witness whereof, I have hereunto set my hand this 4th day of March 2016 at
Davao City, Philippines.

JAREN CAUILAN VILLAROZA

AFFIANT

SUBSCRIBED and sworn to before me this 4th day of March 2016 at Davao City,
Philippines, Affiant exhibiting to me his School Alumni ID No. 08-791 issued at
Koronadal City, South Cotabato.

NOTARY PUBLIC

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