REPUBLIC OF THE PHILIPPINES )

QUEZON CITY ) S.S.

AFFIDAVIT OF UNDERTAKING

I, , of legal age, with residence at , after having been sworn to in accordance with
law, hereby depose and state that:

1. I am applying for the position of _________ with office located at

__________________, Quezon City;

2. I hereby undertake to undergo a Neuro-Psychiatric Examination at the National

Center for Mental Health upon referral of the ______________.

3. This affidavit is executed to attest to the truth of the foregoing and as fulfillment
of one the requirements for application for the position of ___________

IN WITNESS WHEREOF, I hereby sign this Affidavit of Undertaking this 11 th

day of May 2016 at Quezon City, Philippines.

Affiant

SUBSCRIBED AND SWORN TO before me this 11th day of March 2016, affiant
exhibiting to me his ________---, bearing his photograph and signature.

Doc. No. NOTARY PUBLIC

Book No.
Page No.
Series of 2016.