Republic of the Philippines)

City of ) S.S

AFFIDAVIT OF NON-RECEIPT
OF BOARD CERTIFICATE

I, __________________________, of legal age, Filipino and presently residing at

________________________________, after having been duly sworn to in accordance with
law do hereby depose and say:

1. That I passed the __________________ Engineering Licensure

Examinations which was held on _______________________;

2. That I registered with the Professional Regulation Commission on

____________________and was issued with PRC License No.
____________________;

3. But to this date, I have not received my copy of the Board Certificate for
_______________;

4. That I have neither received, endorsed, assigned nor appointed anybody to

receive the Board Certificate on my behalf;

5. That I am executing this affidavit to attest to the truth of the foregoing facts,
without any intention of misleading the authorities as to the real
circumstances surrounding non-receipt of the Board Certificate, and to
support my application for the issuance of a new Board Certificate.

In witness hereof, I have hereunto affix my signature this ___________ day of

___________ at ________________.

_________________________
Affiant

SUBSCRIBED AND SWORN to before me this ________ at

______________________, Affiant exhibiting to me his competent evidence of identity by
way of ____________________________ issued at __________________
on_______________________.

NOTARY PUBLIC

Doc No.
Page No.
Book No.
Series of 2023