Affidavit Of Continuous Compliance
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1Form No.:
QWP-CDRRHR-4-02-Annex 6
Revision:
01
AFFIDAVIT OF CONTINUOUS COMPLIANCE
I, ________________________________________, of legal age, single/married, and a resident
of ___________________________________________________________, after having been
duly sworn to in accordance with the law hereby voluntarily depose and state:
1.
That I am the lawful registered owner/legal person/radiation protection officer of
_____________________________________________________ with business address at
___________________________________________________________.
2.
That prior to the renewal of my license to operate (LTO) an x-ray facility for the year
_______, I am faithfully, religiously, and completely complying with the licensing
requirements of the Department of Health
3.
That by virtue of this sworn statement, I manifest to the Center for Device Regulation,
Radiation Health, and Research (CDRRHR) that my facility is continuously complying with
the licensing requirements to ensure safety both on the radiation workers and the public.
4.
That
if
the
Health
Physics/Enforcement
team
of
the
CDRRHR
conducted
monitoring/inspection of my x-ray facility and found to have deficiencies, I shall be liable
for any sanction to be imposed by the CDRRHR-FDA of the Department of Health pursuant
to the Republic Act No. 9711 and its Implementing Rules and Regulations and /or other
implemented laws of the FDA and the DOH.
5.
That this affidavit releases the CDRRHR of any legal liability in connection with the
renewal of our LTO.
6.
That I am executing this affidavit as a requirement for the renewal of my license to operate
an x-ray facility.
IN TRUTH WHEREOF, I have hereunto signed my name below, this
day of
at
Manila.
______________________________
Affiant
(Owner/Legal Person/RPO)
SUBSCRIBED AND SWORN to before me, this _____ day of________________200__
in __________________________________________, affiant exhibiting his/her Community tax
Certificate No.__________ issued at ___________________on______________________.
___________________
Notary Public
Doc No. _______
Page No. _______
Book No._______
Series of 201____
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