_______________________________ ___________________________________

MEMORANDUM OF AGREEMENT
KNOW ALL MEN BY THESE PRESENTS:

This AGREEMENT made and executed by and between

MARIVELES MENTAL WELLNESS AND GENERAL HOSPITAL, a Government Institution herein

represented by MARIA LOURDES L. EVANGELISTA MD, FPPA in her personal capacity as Medical Center
Chief, of legal age, Filipino, with residence and postal address of P. Monroe St. Brgy. Poblacion, Mariveles,
Bataan hereinafter referred to as the PARTY OF THE FIRST PART;

-AND

_______________________, with business and postal address at ________________________, a

duly recognized Institution by the Commission on Higher Education, represented by
___________________________________, hereinafter referred as the PARTY OF THE SECOND PART.
Dean

WITNESSETH:
University President

1. That the PARTY OF THE FIRST PART agrees and allows the affiliation and training of the NURSING
of the PARTY OF THE SECOND PART subject to the Policies, Procedures, and Guidelines governing
the Affiliation and Training of Students in the Department of Health Hospitals/Rural Health Units and
other Health Agencies and that the Chief of the Agency representing the PARTY OF THE FIRST PART
shall be responsible and liable to the fullest extent any violation of the Provisions in the Joint
MRIA LOURDES L. EVANGELISTA, MD, FPPA

Administrative Order of Department of Health Administrative Order No. 2013-0034 and

Commission on Higher Education Memorandum Order No. 35 s. 2013. Likewise, the PARTY OF
THE SECOND PART shall strictly comply with the provisions of the said Joint Administrative Order and
any violation thereof shall be a legitimate ground for the cancellation of the contract;

2. WHEREAS, the PARTY OF THE FIRST PART is a Government Hospital wherein the students of
health related courses from Accredited Universities / Colleges are rendering their internship;

3. WHEREAS, the PARTY OF THE SECOND PART will send its Nursing Students to render health care
to patients of the PARTY OF THE FIRST PART anytime from _________________ to
Medical Cemter Chief

_______________.

NOW, THEREFORE, for and in consideration of the foregoing premises and consideration of the express
stipulations and covenants herein agreed upon, the parties have hereunto agreed to be bound by the following
ROLANDO F. BONIQUIT II, PTRP, RN

terms and conditions, to wit:

1. That honesty, integrity and courtesy shall always be observed by the students of the PARTY OF THE
SECOND PART when rendering services inside the Hospital; any conduct unbecoming of a student
HCATS CHAIRPERSON

shall be dealt with accordingly and may serve as basis to suspend his/her training;

2. That the PARTY OF THE FIRST PART shall not be liable to any harm and damages due to accident
or unavoidable circumstances that may occur to students/Clinical Instructors during their training.

3. That the PARTY OF THE FIRST PART shall be the one to determine the schedule of training time and
MARIVELES MENTAL HOSPITALSchool

areas of assignment of the students of the PARTY OF THE SECOND PART.

RELIA I VILLEGAS, RN, MAN, EdD

4. That the PARTY OF THE FIRST PART has the right to cancel the existing contract if the PARTY OF
THE SECOND PART has not complied with the rules and regulations set forth in this contract and in
the event of changes in policies made by the institution.
Chief Nurse

5. That the PARTY OF THE SECOND PART shall settle the corresponding affiliation fees on the clinical
training of their students before the commence of training time to the PARTY OF THE FIRST PART
representatives. (Corresponding fees are subject to change in consultation with DOH and CHED)

IN THE WITNESS WHEREOF, the parties have affixed their signatures this _____________________, at the
Mariveles Mental Wellness and General Hospital, Mariveles, Bataan.

MARIA LOURDES L. EVANGELISTA, MD, FPPA

MOA_Nursing_revised Mar 2023

Medical Center Chief _______________________________
University President

SIGNED IN THE PRESENCE OF:

ROLANDO F. BONIQUIT II, PTRP,RN _______________________________

HCATS CHAIRPERSON Dean, Nursing Department

RELIA I. VILLEGAS, RN, MAN, EdD

Chief Nurse/ Nursing Service

ACKNOWLEDGEMENT

REPUBLIC OF THE PHILIPPINES

PROVINCE OF BATAAN
CITY OF BALANGA

BEFORE ME, this _____________________, Notary Public in and for the _______________________,
Philippines, personally appeared ______________________________________ with Residence Certificate No.
_________________________________, issued at ___________________________________________, on
_____________________, and MARIA LOURDES L. EVANGELISTA, MD, FPPA, with Residence Certificate No.
______________, issued at ___________________________________________ on _____________________. Both
know to me to be the same persons who executed the foregoing instrument and they acknowledged to me that the same
is their free act and voluntary deed.

This instrument consisting of two pages, including this page on which this acknowledgement is written has been
signed on each and every page thereof by the parties hereof and their witnesses and sealed with the notarial seal.

IN WITNESS WHEREOF, I hereto set my hand, the day year and place above written.

___________________________
DOC. NO. _____________ NOTARY PUBLIC
PAGE NO. _____________
BOOK NO. _____________
SERIES OF _____________

MOA_Nursing_revised Mar 2023