REPUBLIC OF THE PHILIPPINES)

Municipality of Palompon ))S.S

AFFIDAVIT OF CONSENT

I, IAN JAY L. AREVALO, Filipino of legal age, and a resident of Brgy. San Isidro, Palompon
Leyte, Philippines, having been duly sworn in accordance with the law, hereby depose and state:

1. I am the PRESIDENT of BLUESKY ARRASTRE AND STEVEDORING SERVICES INCORPORATED

(BASSI) an entity engaged in the business of CARGO HANDLING OPERATIONS, with a
principal office and business address at BRGY. CENTRAL II, PORT AREA, PALOMPON, LEYTE.

2. That as part of the requirements of the Local Government Unit of Palompon, through the
Business Permit and Licensing Section, I have installed a CCTV camera;

3. That I hereby signify my written consent, freely, willingly, and voluntarily to allow our office
(BPLS) Office of the Municipal Mayor, Office of the Building Official (OBO), and Police Officers
of the Municipal Police Station of Palompon Leyte to access the CCTV camera installed
within the premises of my business establishment;

4. That I am executing this affidavit to attest the truth of the foregoing facts as to my
undertaking to give consent to the police officers to access my CCTV Camera.

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

Palompon Leyte, Philippines.

IAN JAY L. AREVALO

Affiant

SUBSCRIBED AND SWORN to before me, this ___ day of ___________, at Palompon Leyte,
Philippines.

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