OFFICE GF THE PRESIDENT. DANGEROUS DRUGS BOARD Annex “B” ‘THE HONORABLE Undersecretary EARL P. SAAVEDRA. Executive Director Dangerous Drugs Board 3° Fir., DDB-PDEA Bidg,, NIA Northsite Road, National Govt. Center, Bray., Pinyahan, ‘Quezon City SUBJECT: APPLICATION FOR VOLUNTARY CONFINEMENT FOR ‘TREATMENT AND REHABILITATION THRU REPRESENTATION SIR tam , of legal age, Filipino and ‘(Name of applicant-representative) resident of ‘(Complete adress) and of (relation to drug dependent) (name of drug dependent) years old and resident of The said is a victim of drug abuse, using ‘and, for and in his/her behalf, | wish to (kind oF drugis used) voluntarily submit him/her for confinement for treatment and rehabilitation at the (name and address of drag treatment and rehabiltation center) ee pursuant to Section 54, R. A. 9165, otherwise known, as The Comprehensive Dangerous Drugs Act of 2002 and Dangerous Drugs Board Regulation No. 3, S. 2007. This is his/her {ime to apply for voluntary confinement, either personally (io. oftimesy or thru representation For the Board's favorable consideration. ‘Name and Signature of Applicant - ‘Representative Conforme: Name and Signature of Drug DependentVERIFICATION of legal age, Filipino, and with residence and postal address at after having been duly swom to in accordance with law, hereby depose and state 1. That | am the applicant for the voluntary confinement for treatment and rehabilitation of ; under Section 54, RA 9165, otherwise. known as The. Comprehensive Dangerous Drugs Act of 2002 and Board Regulation No. 3, Series of 2007; 2. That | have read and fully understood the contents of the application, finding them true and correct according to my own knowledge, information and beliet. ‘Name and Signature of Affiant SUBSCRIBED AND SWORN to before me this _day of. i 2019 in affiant exhibited to me hisiher CTC with No, issued at on NOTARY PUBLIC Doc. No. Page No. Book No. Series of 2019 APPROVED / DISAPPROVED: Atty. DANIEL A. ADEVA Ill Duly Authorized DDB Representative