REPUBLIC OF THE PHILIPPINES }

CITY OF CAGAYAN DE ORO…………..}

AFFIDAVIT OF LOSS

I, _____________________, Filipino, of legal age, married and a resident of

___________________________ after having duly sworn to in accordance with the law
hereby depose and say that:

1. I am a licensed Physician here in the Philippines.

2. As such, I am a holder of a Physician Identification Card with ID No.

______________ issued by the Professional Regulation Commission
(PRC).

3. On _______________, I was surprised to find out that I could not locate

my PRC ID. It must have fallen out of my bag or pocket.

4. I exerted earnest efforts to find my PRC ID, but I could no longer

locate it, thus I considered it lost for all legal purposes.

5. The said Identification Card 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. I am executing this affidavit to attest to the truthfulness and veracity

of the foregoing facts, and for the purpose of securing another PRC
ID, and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

____________________ in the ________________________, Philippines.

______________________
Affiant

SUBSCRIBED AND SWORN to before me this ____________________ in the

____________________, Philippines. Affiant exhibited to me his
_____________________________ with an expiration date of ___________________, as
competent evidence of identity.
Doc No. _____
Page No. _____
Book No. _____
Series of 2023.