REPUBLIC OF THE PHILIPPINES

PROVINCE OF NEGROS OCCIDENTAL

CITY OF _____________________
X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X-X

SWORN STATEMENT OF APPLICANTS

I hereby certify under oath that I have been actually enrolled in the schools listed in the
accompanying transcript of records and that I have actually earned the units therein. As required
by the Department of Education has been furnished with authentic copies of the sworn statement
and its enclosure.

________________________
Signature of Applicant

Subscribe and Sworn to before me this _____________ day of __________________.

Affiant exhibiting his/her Residence Certificate Number __________________________. Issued
at __________________________________ on ______________________________.

____________________________________
Signature of Person Administering Oath

Doc. No. __________

Page No. __________
Book No. _________
Series of __________

Documentary
Stamp