WITHDRAWAL FORM

I, _________________________________, legal age, Filipino and resided at

__________________________________, Philippines, after having been sworn in
accordance with the law, hereby depose and say, that;

1. Due to ______________________________________________ which is beyond my

control, I now withdraw my application from Golden Horizon Placement Agency Inc.
and Al Mostaqbal Domestic Workers Services L.L.C. and this withdrawal I voluntarily
undertaken.

2. I applied as _______________________ at _________________.

3. I hereby release and hold the Golden Horizon Placement Agency Inc. and Al
Mostaqbal Domestic Workers Services L.L.C. its officers, employees free from any
civil, criminal or administrative case which I may have or will have in the future as a
result of my overseas employment.

4. I am executing this to attest to the truth of forgoing statements and to dismiss my

monetary claims and to attest that my acts of terminating this case is made willingly
and voluntarily free from duress, force or intimidated and with full knowledge of my
rights under the laws.

IN WITNESS WHEREOF, I HAVE HEREUNTO SET BY MY HANDS, THIS ______ DAY OF

________ YEAR _____________.

___________________________________
Signature over printed name of applicant

SUBSCRIBED AND SWORN TO BEFORE ME THIS _________ DAY OF ________ YEAR

________, AFFIANT EXHIBITING TO ME HIS/HER PASSPORT NO. ________________.

Doc. No. Documents withdrawn

Page No.
Book No. ____ Passport original
Series of. ____ Medical Certificate
____ PDOS Certificate
____ Ereg
____ Peos