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Annex A-3 Sworn Undertaking

FDA RFR sworn undertaking

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Republic of the Philippines)
City of _______________) S.S.
SWORN-UNDERTAKING
I, ___________________________________, _______________________________, with business
(Service Provider)
(Position)
address at _____________________________, do hereby solemnly swear, in accordance with the law:
(address of the Service Provider)
1. That _____________________________hereby appoints _________________________, as represented
(Service Provider)
(Principal Contractor)
by ______________________________, ___________________________ and with business address at
(Name)
(Position)
_______________________________________ to be the duly authorized principal contractor of the
service provider responsible for :
1. Installation/construction/or operation of cell sites of ____________________________ as listed below:
(Service Provider)
2.
____________________________________________________________________________________
(State others, if any)
2. As such, _______________________________ shall be solely responsible for applying and securing the
(Principal Contractor)
DOH-Desktop Radio Frequency Radiation (RFR) Safety Evaluation Report pertaining to the
installation/construction/or operation by __________________________________ cell sites including the
(Service Provider)
submission of Site Specifications and Conceptual Drawing, a letter-request for an RFR evaluation of
_______________________________ facilities and equipment and other pertinent documents.
(Service Provider)
3. If ______________________ decides to subcontract the prosecution of the above-mentioned project,
(Principal Contractor)
appointments for authorized sub-contractors shall exclusively originate and be issued by
___________________________. The said authorization shall be attached to this undertaking.
(Principal Contractor)
4. That both ___________________________ and ______________________ warrant that any information
(Service Provider)
(Principal Contractor)
disclosed in any of the documents submitted to the Center for Device Regulation, Radiation Health and
Research of the Food and Drug Administration (FDA), Department of Health are true, complete, and
accurate. In the event of misrepresentations or falsifications committed by any employee, agent or
substitutes of either the service provider or the principal contractor pertaining to documents submitted to
and/or received from the CDRRHR, both shall be jointly and solidarily liable for the penalty to be
imposed by the Director IV of the Center for Device Regulation, Radiation Health and Research.
IN WITNESS WHEREOF, we have hereunto affixed my signature on this ___ day of _____, 201__.
___________________________________
(Service Provider)
Community Tax Certificate No.___________
Issued on: _____________
Issued at: _____________

_________________________________
(Principal Contractor)
Community Tax Certificate No.________
Issued on: _____________
Issued at: _____________

SUBCRIBED AND SWORN TO before me this ____ day of ______ 201___ with both representatives
exhibiting to me their respective Community Tax Certificates.
Doc. No.
Page No.
Book No.
Series of _______.
 
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