ANNEX “C”

REPUBLIC OF THE PHILIPPINES )

ILOCOS NORTE ) Sc.

AFFIDAVIT OF UNDERTAKING
I, ________________________, of legal age and resident of ____________________
_________________________ after having been duly sworn according to law, hereby depose
and state that:

1. I am a resident of _____________________ and declare that I am an authorized

person outside residence (APOR);

2. To the best of my knowledge, I am not infected with COVID-19;

3. I am an employee of ___________________________, occupying the position of

_________________________;

4. The organization I work for is at full operational capacity thus I’m required to
be physically present and discharge the duties and functions of my office;

5. As I enter the Province of Ilocos Norte, and by virtue of this affidavit, I

undertake to:

a. Agree to undergo comprehensive health check by staff from Provincial

Health Office upon the arrival at the provincial boarder at Municipality of
Badoc, Ilocos
Norte/Municipality of Pagudpud, Ilocos Norte;
b. Present Identification card and other documents to show the nature of my
work;
c. Submit proof/s of residency;
d. Divulge the name, contact number, company, company contact name and
number, and the duration of stay in Ilocos Norte;
e. Undergo decontamination process by Bureau of Fire Protection (BFP); and
f. Work from home when at all possible and minimize my time at the work
place, not roam, and comply with strict health protocols.
g. Fill up APOR Health Declaration Form
h. Shall not bring any travel companions

6. That should I stay overnight in the province, I shall submit a copy of this
Affidavit of Undertaking to the Barangay Captain (or his/her representative)
of the place of temporary residence.

I am executing this affidavit as my voluntary act and deed for whatever legal intents
and purposes it may be worth.

IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ____________ at

_________________.

___________________________
Affiant
I.D. No. ________________
SUBSCRIBED AND SWORN TO before me this ___ day of _________ 2020. That I have
examined the affiant and s/he declared to me that s/he had read and understood the
foregoing, his/her voluntary act and deed and that the same are true to the best of his/her
knowledge and based on authentic records.

Doc. ______;
Page _____;
Book _____;
Series of 2020.