REPUBLIC OF THE PHILIPPINES

CITYOF QUEZON

AFFIDAVIT OF LOSS

I, Carla L. Dela Cruz, Filipino, of legal age and a resident of The Redwoods Condominium, Kaji 210, Pasong
Putik Proper, Novaliches, Quezon City, after having duly sworn to in accordance with the law, hereby depose and say
that:

1. Iam a holder of a Certified Physician Identification Card issued by Professional Regulation Commission;

2. I lost said Identification card on May 10, 2014, and that I exerted all my efforts to locate the same but I could
not remember exactly where I placed it and it is considered lost for all legal purposes;

3. 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;

Iam executing this affidavit to attest to the foregoing facts;

IN WITNESS WHEREOF, I have hereunto set my hand this 20th of May in the City of Quezon, Philippines.

CARLA L. DELA CRUZ

Affiant

SUBSCRIBED AND SWORD to before me this in the City of , Philippines,

affiant having exhibited to me his/her community tax certificate with no. issued
on at .

Doc. No:
Page No:
Book No:
Series of