(Company Letterhead)
STATEMENT OF MANAGEMENT’S RESPONSIBILITY
On behalf of (Company Name) (the “Company”), the undersigned Authorized Representative of the
Company hereby submits the Company’s Masterlist of Employees (the “Employee List”) to apply for and
avail of the National COVID-19 Vaccination Program through Project Balik Buhay. We attest that the
employees listed in the Employee List have all voluntarily, and of their own volition, agreed to be
vaccinated and to apply in the National COVID-19 Vaccination Program through Project Balik Buhay. We
attest further that the employees listed in the Employee List have not been vaccinated for COVID-19 and
they have not applied with the Department of Health or their relevant Local Government Unit for
COVID-19 vaccination.
We confirm and certify that all the information provided in this application and those contained in the
Employee List are true, accurate, and complete. We confirm further that the Company has complied
with all applicable data protection laws particularly the Data Privacy Act of 2012. We confirm
furthermore that the employees have been made aware that the data, including their personal and
sensitive personal information, will be used, stored, shared, and collected for the purpose of
implementing the National Covid-19 Vaccination Program of the government. We attest and confirm
that each employee has given their full consent to the collection, use, sharing and storage to enable the
Government to carry out the vaccination. The employees have been made to understand that the data
will be stored for the period of time that is necessary to complete the vaccination process.
The Company hereby agrees to indemnify and hold Project Balik Buhay free and harmless from any
damages, costs, or liabilities arising from any erroneous or incorrect information provided in this
application.
(Name in Print)
AUTHORIZED REPRESENTATIVE
Conforme: (Name in Print)
CHIEF EXECUTIVE OFFICER (or equivalent)
Signed this _____ day of _________