CONFIRMATION, UNDERTAKING AND WAIVER

KNOW ALL MEN BY THESE PRESENTS:

I, ________________________________, of legal age, and a resident of

_________________________________________________, after being duly sworn in accordance with law, hereby
depose and state:

I am the _____________________ of Star Appliance Center, Inc. and currently assigned at

______________________. I am currently pregnant with the expected date of birth of my child on
______________________.

I confirm that I have been advised by my employer to take a leave-of-absence due to the ongoing COVID-19
pandemic as a precautionary measure due to my current condition and as required by the relevant IATF and DOLE
guidelines. Despite such advice, I have decided to continue reporting to work and to perform my responsibilities as
___________________. For this purpose, I have likewise secured the appropriate medical clearance and advice from my
doctor or physician.
.
In this regard, I undertake to observe the following with respect to the performance of my duties and
responsibilities to the Company for the duration of my pregnancy:

(a) Report to work during regular office hours at ________________________;

(b) Strictly wear the required masks, face shields and other PPEs as may be necessary while inside company
premises;
(c) Attend all required external meetings virtually;
(d) Maintain strict social distancing when interacting with co-employees and other people in the office; and
(e) In general, observe all safety protocols in the workplace as may be required by the Company and/or
mandated by government regulations.

In view of the foregoing, I hereby waive any claim, right of action or remedy which I may have against the
Company, its owners and managing company, its affiliates or subsidiaries and their officers, managers, agents,
stockholders, successors and assigns its owners in connection with any disease, injury, disability, or health complication
arising from the performance of the tasks during this period of community lockdown and which may be traced to any
possible exposure to the COVID-19 virus and, by these presents do, for myself and for my heirs, successors and assigns,
hold the Company, its owners and managing company, its affiliates or subsidiaries and their officers, managers, agents,
stockholders, successors and assigns free and harmless from any and all manner of action or actions, cause or causes of
actions, sum or sums of money, accounts, damages, claims and demands whatsoever, in law or in equity arising from
such exposure during the period of my pregnancy.

I hereby declare that I have read this document and the contents hereof were understood by me before signing it
and the waiver and release hereby given is made willingly and voluntarily and with full knowledge of my rights as well as
the right of son/daughter under the law.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of ______________ in
______________________.

____________________________
Affiant

SIGNED IN THE PRESENCE OF:

__________________________ __________________________

REPUBLIC OF THE PHILIPPINES )

__________________ ) S.S.

BEFORE ME, a Notary Public in and for ________________, this ____ day of __________, 2021, personally
appeared _________________________, with Community Tax Certificate No. ________________, issued at
____________________ on ___________________, known to me and to me known to be the same person who
executed the foregoing Certification and Waiver and who acknowledged to me that the same is his free and voluntary act
and deed.

WITNESS MY HAND AND SEAL on the date and at the place first above written.

Doc. No. _____;

Page No. _____;
Book No. ____;
Series of 2021.