Republic of The Philippines) City of Dumaguete) S.S.: Notary Public

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REPUBLIC OF THE PHILIPPINES )

City of Dumaguete)S.S.

AFFIDAVIT OF LOSS

I, RUBY ZAMORA, Filipino, of legal age, residing at Fortune Homes, Pulantubig,


after having been sworn in accordance with law hereby depose and state:

1. That I am a holder of a PRC Board of Certificate, having passed the Nursing


Board examinations undertaken by the Philippine Regulatory Commission;

2. That sometime this July of this year, I was looking for the PRC Board of
Certificate but to my surprise, said certificate could not found;

4. All my efforts to recover said receipt was to no avail;

5. That I am executing this affidavit for the purpose of affirming the truth of the
foregoing statements and for any legal purpose this may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of


_______________. 20___ at _________________________.

RUBY ZAMORA
Affiant

SUBSCRIBED AND SWORN to before me this ______th day of


______________, 2018. Affiant exhibiting to me his evidence of identity
___________________________.

NOTARY PUBLIC
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20_______.

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