Affidavit of Loss (Jay-r)

Republic of the Philippines) City of Manila ---------------)ss AFFIDAVIT OF LOSS I, ADOLPH PAMARAN GUERZON Jr. , of legal age, single , Filipino and with post office address at Block 2 Lot 5 Adelina 2A, San Pedro, Laguna, after having been duly sworn to in accordance with law, hereby depose and state: 1. That I am a duly licensed professional nurse having passed the Board Examination for Nursing in 2008; 2. That I was issued my PRC License in 2008 , Reg. No. 0501372 and expired in my birthmonth May 2011; 3. That I applied for renewal with the Professional Regulation Commission during the first week of May but my PRC License ID has not yet been issued up to the present; 4. That when I followed up again my license last week, I could no longer locate the claim stub that was issued to me and despite deligent efforts I failed to locate the same and I know that it was already lost and could no longer be recovered; 5. That I am executing this Affidavit to inform PRC that the claim stub issued to me to claim my PRC License was lost and never recovered and for the purpose of getting my PRC License despite loss of muy claim stub. In witness whereof, I have hereunto set my hand this ____ day of August 2011 at Manila , Philippines.

ADOLPH PAMARAN GUERZON JR. AFFIANT SUBSCRIBED and sworn to before me this ____ day of August 2011 at Manila, Philippines, Affiant exhibiting to me his Drivers License No. N26-09015930 issued at Las Pinas City expiring May 12, 2012. NOTARY PUBLIC Doc. No. Page No. Book No. Series of 2011