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AFFIDAVIT OF LOSS OF IDENTIFICATION CARD

REPUBLIC OF THE PHILIPPINES )


CITY OF MANILA ) SS.

I, MARK JAY GALLEGO LOPEZ, Filipino, of legal age, single, and a resident of 56 Tirad
Pass, Bagong Barrio, Caloocan City, after having been duly sworn in accordance with law,
hereby depose and say:
1. That I am a holder of a professional identification card issued by the Professional
Regulation Commission (PRC) for being a Registered Nurse;
2. That sometime on October, 2012, I discovered that my wallet was missing where I
used to put my PRC identification card, among others;

3. That diligent search of said PRC Identification card proved futile and unavailing;

4. That said ID card was not confiscated by the authorities by reason of violation of any
rules and regulations;
5. That I am executing this affidavit to attest to the truth of the foregoing facts and to
request for a replacement of said PRC ID card from the Professional Regulation
Commission.
IN WITNESS WHEREOF, I have hereunto affixed my signature this 8
th
day of November
2012 at Manila, Philippines.


_________________________________
MARK JAY G. LOPEZ
Affiant

SUBSCRIBED AND SWORN to before me, this ______ day of November, 2012 in the City of
Manila, affiant exhibiting before me his ______________________, issued at ______________
on _____________.

Notary Public


Doc. No. ..;
Page No. .;
Book No. .;
Series of 2012.

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