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Republic of the Philippines )

Legazpi City ) S.S

MEMORANDUM OF UNDERTAKING

KNOW ALL MEN BY THESE PRESENTS:

I, __________________________, owner/head of facility of


__________________________located in _________________________, under oath, aver, as
follows:
1. That above named facility was found to be deficient of some requirements during 2018
monitoring visits, to wit:

a. Personnel Complement

b. Physical Plant

c. Equipment/Instruments

d. Others

2. That in view of our application for renewal of 2019 License to Operate, I undertake to
comply with the above requirements, under the following conditions:

a. That until such time that the facility completely comply with the above
requirements, the License to Operate of the facility shall be deemed ineffective and
shall be validated only after full compliance of the requirements.

b. That upon order of Department of Health Center for Health Development – Bicol,
the facility shall cease and desist from operating until the License to Operate
becomes valid.

IN WITNESS WHEREOF, I have been hereunto set my hand this _ _ day of _ _ _ _ _ _ _ _ _


_, 2018 in _____________.

_______________________
Owner/ Head of Facility
SIGNED IN THE PRESENCE OF:

1. ______________________________ 2. _______________________________

ACKNOWLEDGEMENT
REPUBLIC OF THE PHILIPPINE )
PROVINCE OF _________ ) S.S
MUNICIPALITY OF ________

BEFORE ME, notary public for and in the above jurisdiction, this __th day of _______,
personally appeared:

NAME GOV’T ISSUED ID NO. Issued by:

_______________________ ______________________ _________________


_______________________ _______________________ _________________

All known to me and to me known to be the same persons who executed the foregoing
instrument and they acknowledged to me that the same is their free and voluntary act and deed.
This instrument consisting of two pages (2) pages, including the page where this
acknowledgement is written has been signed by concerned party on each and every page
thereof.

IN WITNESS WHEREOF, I have hereunto set my hand in the place and date above written.

Doc. No. ____ NOTARY PUBLIC

Page No.____

Book No. ____

Series of 2018