Republic 

of the Philippines)
City of Baguio ) S.S.
x---------------x

AFFIDAVIT OF LOSS

I, __________________, of legal age, Filipino and a resident of -

__________________ after having been duly sworn according to law, depose
and state:

1. That I am a registered nurse and a holder of a Professional Regulation

Commission (PRC) Identification Card bearing the registration number -
__________________, additionally, I was issued a Board Certificate by
the PRC;

2. That sometime in 2020, I noted that said PRC Board Certificate was lost;
3. I believe that the aforementioned Board Certificate was misplaced by my
family members in __________________while I was staying in Baguio
City;
4. That despite diligent search and efforts to locate my PRC Board Certificate
I could not find the same, such that I now believe that it is now lost and
beyond recovery;
5. Said PRC Board Certificate 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; and neither was it offered as
collateral for any loan;

6. As such, I am executing this Affidavit of Loss to attest to the truth of the

foregoing and to support my application for the issuance of a PRC Board
Certificate, in lieu of the one that was lost and for all legal intents and
purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 10th day of August
2021 at Baguio City, Philippines.

__________________
Affiant
ID: __________________

SUBCRIBED AND SWORN TO before me a Notary Public for and in Baguio

City this this 10th day of August 2021 in Baguio City, Philippines, affiant exhibiting
to me his proof of identification.

Doc. No.
Page No.
Book No.
Series of 2021.