Republic of the Philippines)

City of _______________) S.S.

AFFIDAVIT OF UNDERTAKING

I, ___________________________________, ________________________of ____________________________.

(Representative of Service Provider) (Position) (Service Provider)
with business address at __________________________________________________, do hereby solemnly swear,
(Address of the Service Provider)
in accordance with the law:

1. That _____________________________ hereby appoints _________________________, as represented

(Service Provider) (Principal Contractor)
by ________________________________, ___________________________ and with business address
(Representative of Principal Contractor) (Position)
at _______________________________________ to be the duly authorized principal contractor of the
(Address of Principal Contractor)
service provider responsible for the installation of Radiofrequency Radiation (RFR) equipment of
____________________________.
(Service Provider)

2. As such, _______________________________ shall be responsible for applying and securing the

(Principal Contractor)
Certificate of Safety Evaluation (CSE) from the Food and Drug Administration, pertaining to the
installation of RFR equipment, including the submission of Conceptual Drawing / Floor Plan, Site and
Antenna specifications.

3. If ________________________________ decides to subcontract the execution of the above-mentioned

(Principal Contractor)
project, the following constitutes the list of accredited companies hereby authorized by
__________________________ to secure CSE as subcontractors, on their behalf:
(Principal Contractor)
a. ____________________________ c. ____________________________
b. ____________________________ d. ____________________________

4. That both ___________________________ and ______________________ warrant that any information

(Service Provider) (Principal Contractor)
disclosed in any of the documents submitted to the Center for Device Regulation, Radiation Health and
Research of the Food and Drug Administration (FDA), Department of Health are true, complete, and
accurate. In the event of misrepresentations or falsifications committed by any employee, agent or
substitutes of either the service provider or the principal contractor pertaining to documents submitted to
and/or received from the CDRRHR, both shall be jointly and solitarily liable for the penalty to be
imposed by the Center Director of the Center for Device Regulation, Radiation Health and Research.

IN WITNESS WHEREOF, we have hereunto affixed my signature on this ___ day of _____, 202__.

___________________________________ _________________________________
(Service Provider) (Principal Contractor)

Community Tax Certificate No.___________ Community Tax Certificate No.________

Issued on: _____________ Issued on: _____________
Issued at: _____________ Issued at: _____________

SUBSCRIBED AND SWORN TO before me this ____ day of ______ 202___ with both
representatives exhibiting to me their respective Community Tax Certificates.

Doc. No.
Page No.
Book No.
Series of _______.