Affidavit of Authenticity

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Republic of the Philippines)

_________________________)S.S.
x---------------------------------------x

AFFIDAVIT OF AUTHENTICITY

I, ________________________, of legal age, __________________, Filipino citizen,


and a resident of ________________________, after having been duly sworn to in
accordance with law hereby depose and states that:

1. I am applying for a Student Visa;

2. That in compliance with some requirements, I have submitted the following


photocopies of my documents, to wit:
a. Photocopy of my Polish Medical Certificate;
b. Photocopy of my Medical Certificate issued by Notre Dame De
Chartres Hospital; and
c. Photocopy of my Certificate of Live Birth issued by Philippine
Statistics Authority.

3. I am executing this affidavit to attest to the truthfulness of the foregoing


narration of facts and for whatever intents and purposes it may legally
serve.

IN WITNESS WHEREOF, I have hereunto set my hand this


__________________ in the ___________________, Philippines.

____________________________
Affiant
_______________________

SUBSCRIBED AND SWORN to before me this ____________________ in the


_________________________, Philippines. Affiant exhibited to me his valid
identification as indicated below his typewritten name.

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