Republic of the Philippines )

CITY OF MANILA )S.S.

VERIFIED UNDERTAKING

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 wit:

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 employed;

11. AFFIANT FURTHER SAYS NONE.

SIGNED this day of ___________________________, 2017 at .

Affiant/Applicant

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 same.

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

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