AFFIDAVIT OF UNDERTAKING FORMAT

FM-POEA-06-ESRD-03-b-SRA

Effective May 16, 2012

REPUBLIC OF THE PHILIPPINES               )

MANDALUYONG, METRO MANILA       ) S.S.

AFFIDAVIT OF UNDERTAKING

I, ______________________________________, of legal age, single/married, Filipino, a resident of ____________________________________ and with business address at _________________________________________ after having been subscribed to an oath, depose and say:

1. That I am the incumbent ______________________________________________________

( position of affiant)

of ___________________________________________, a domestic corporation organized under

( name of agency)

Philippine Laws, and a duly licensed recruitment agency as per License No. _____________________________ issued by the Philippine Overseas Employment Administration;

2.       That as licensed recruitment agency, we requested the POEA to issue in our favor an authority to conduct recruitment activities in the following provinces/cities on the corresponding dates:

_______________________________________________        _________________________

_______________________________________________        _________________________

_______________________________________________        _________________________

3. That in my capacity as _________________________ of the ________________________

       ( position of affiant)                        (name of

__________________________, I hereby DECLARE and ASSUME full responsibility in the orderly

           agency)

conduct of recruitment activities of  __________________________________________ who has

        (name of representative)

been authorized to represent our agency in the recruitment activities in the above-mentioned place/s and date/s;

4.       That I likewise DECLARE and ASSUME full and complete responsibilities for all consequences which may arise in connection with the conduct of above recruitment activities;

5.       That I execute this Affidavit of Undertaking in compliance with the requirements in the issuance of an authority to conduct special/provincial recruitment activity.

In witness hereof, I hereby set my hand this _____^th day of _________________, 20__, in _______________________________.

______________________________________

(Affiant)

SUBSCRIBED AND SWORN to before me this __^th day of __________________________.  Affiant exhibited to me his/her Residence Cert. No. as indicated above below his name.

                                               

                                                                                    NOTARY PUBLIC

Doc. No. ____________

Page No.____________

Book No. ____________

Series of 2012