REPUBLIC OF THE PHILIPPINES )
CITY/MUNICIPALITY OF ____________ )S.S.
x----------------------------------------x
AFFIDAVIT
I,____________________________________, of legal age, and a resident of
_______________________________________________, deployed under the
_______________ with the position of______________________________ from
________________20__ to ______________________20__, after having been duly sworn to in
accordance with law, do hereby affirm as follows:
a. I was oriented and made aware of the job description and its corresponding duties
and responsibilities as well as the potential risks it inherently involves especially
during this time of pandemic, all of which were sufficiently and clearly explained to
me;
b. I understand the duties and responsibilities as well as the risks involved therein;
c. For health and safety reasons, I hereby voluntarily waive my slot in the
_________________ until the current health situation improves and I am ready to
return for deployment under the program;
d. I also acknowledge it is of my own free will and without coercion, whatsoever and
that its contents have been explained sufficiently and clearly to me in a language that
I clearly understand;
e. I voluntarily executed this document in order to attest to the truthfulness of the
foregoing narration for whatever legal intents and purposes it may serve;
IN WITNESS WHEREOF, I have hereunto set my hands this ____________________ at
________________.
_____________________________
(Printed Name and Signature)
Gov’t ID No. ___________________
SIGNED IN THE PRESENCE OF:
_______________________________
(Printed name and signature)