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Republic of the Philippines )



I, , of legal age, M/S, Filipino and a resident

of with Passport No. _______________ issued
on at , under oath states that:

1. I am an applicant for ___________________ in ;

2. Pursuant to my application, I submitted the following documents with

which I affirm and swear to be genuine and authentic, to

a. ;

b. ;

c. ;

d. ;

e. ;

f. ; and

g. ;

3. I hereby undertake that I shall be solely and singly responsible for any and all act/s
of forgery, falsification, falsehood, misrepresentation, non-disclosure of material
facts and other acts of prohibited by the laws of and
of the Philippines committed by me, by persons associated with me or by those who
handled, carried, submitted and processed my documents for submission to

4. I directly applied to based in


5. I did not pay any amount to in relation

to my placement/deployment in ;

6. My employer paid all expenses which

includes processing, service and placement fees;

7. I am fully aware that my application is exclusively based on trust and confidence

which and
government could withdraw at any time upon commission of the prohibited acts or
for loss of trust and confidence;

8. I hereby affirm, confirm and assure , the

employer/principal, the Philippine Government & Government of the
that I am qualified, able and that I am skilled and know the job for which I applied
for, selected and deployed;

9. I hereby undertake to compensate

whatever expenses they may have incurred or damages they may have suffered
relative to my said deployment, which may include, but will not be limited to my
plane ticket or for any damage that they may incur as a result of my acts or
omission that violates the foregoing undertaking;
10.I hereby render free and harmless from
any and all liability/ies that may arise resulting from or arising from any violation on
part of the forgoing undertakingand/or from my inability to perform the job I was


SIGNED this day of ___________________________, 2017 at .


SUBSCRIBED AND SWORN to before me in the City of Manila this _____ th day of
______________________ 2017 by above-mentioned affiant/applicant who has satisfactorily
proven to me his/her identity through his/her Passport No. _____________ valid until
_____________________, that he/she is the same person who personally signed before me the
foregoing Verified Undertaking and acknowledged to me that he/she voluntarily executed the

WITNESS MY HAND AND SEAL this _____th day of __________________ 2017 in the City
of Manila.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2017.