EUMB - EPMPD Doc Ref No.

: EUMB-EPMPD-CEM

Quality Management System Effective Date:

Revision No.: 0
SWORN STATEMENT
(ANNEX F) Page No.: 1 of 1

I, _____________________________, of legal age, single/married, Filipino,

with residence and postal address at
___________________________________________________________________,
after having been duly sworn to in accordance with law, hereby depose and state that:

1. That I worked for ________________________________________

as a ______________________________________________ from
____________________ up to ___________________, as evidence
thereof I have hereto attached a copy of my Employment Certificate
issued by said company dated ___________________ as Annex “A”
and my detailed duties and responsibilities as Annex “B”;

2. That, I am executing this Sworn Statement to attest to the truth of the

foregoing statement and for my application for Certified Energy
Manager (CEM) with the Department of Energy (DOE), Energy
Utilization Management Bureau (EUMB) and undertaking under pain
of administrative, criminal and civil liabilities, and for whatever legal
purpose it may serve.

IN WITNESS WHEREOF, I am affixing my signature this _______ day of

_____________________ 20____ in ___________________________________.

___________________________
Candidate

Reproduction of this Document is not allowed, unless approved by the DOE-EUMB Office of the Director