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Sample Affidavit
PDEA sample affidavit for government practitioners applying for S2
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: REPUBLIC OF THE PHILIPPINES)
CITY OF ____________________)
AFFIDAVIT
I, _______________________________________, of legal age, Filipino, _________________,
(Name)
(Civil Status)
and resident of ________________________________________________________________
____________________________________________________________________________
(Complete Home Address)
after having been sworn to in accordance with the law do hereby depose and declare;
That I am a ___physician / veterinarian / dentist by profession and currently employed at
____________________________________________________________________________
____________________________________________________________________________
(Name of Government Hospital Affiliation with Complete Address)
That I am applying for S2-license at the Philippine Drug Enforcement Agency (PDEA) through
its Compliance Service (CS);
That I guarantee that said S2-license shall be used exclusively for government practice only;
That upon separation from government service, I shall inform PDEA-CS of such separation and
return my S2 license within five (5) working days from said date. Subsequently, I shall apply for
renewal or revalidation of my S2 license as a private practitioner and pay the corresponding fee.
That I am executing this affidavit to attest to the truth of my above-mentioned statement and for
whatever legal purpose this may serve.
In witness whereof I have hereunto set my hand this _______ day of _______________, 20___,
at ________________________________________, Philippines.
_________________________________
(Affiant)
SUBSCRIBED AND SWORN to before me this ___ day of ________, 20___. Affiant exhibited
to me his/her ________________________________as his/her competent evidence of identity.
(PRC license number, registration date)
DOC. NO. ____
PAGE NO. ____
BOOK NO. ____
SERIES OF. ____
(NOTARY SEAL)
NOTARY PUBLIC
