(This sworn statement should be accomplished in four (4) copies and must be notarized by law.
Attached it with the original Transcript of Records required by the Department Order No 12, 2 of
1962)
I HEREBY CERTIFY that I have been actually enrolled in the school or schools on the
accompanying transcript of record and that I have actually earned the units indicated therein. As
required by the Bureau of Higher Education, has been furnished with authentic copies of the
Sworn Statement and its enclosures.
______________________________
(Signature of Teacher)
______________________________
(Printed Name)
---------------------------------------------------------------------------------------------------------------------
SUBSCRIBED AND SWORN to before me this ________________ day of
_________________
20____
affiant
exhibiting
his/her
Residence
Certificate
No.
_____________ issued at ____________________________ on __________________________
I HEREBY CERTIFY that there is no Notary Public within the Municipality of Abulug,
Cagayan.
______________________________
(Administrative Officer)
______________________________
(Designation)
DOC. No. _________
BOOK NO. ________
PAGE NO. _________
SERIES OF 200 ___.