Document No.

: QWP-CDRRHR/RRD-01-Annex 4
Revision: 02

AFFIDAVIT OF CONTINUOUS COMPLIANCE

I, ___________________________________, of legal age, single/married, and a resident

of __________________________________________________________, after having been
duly sworn to in accordance with 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)/certificate of compliance (COC)
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 post-licensing
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_______________201___ at________________________.

______________________________
Affiant
(Owner/Legal Person/RPO)

SUBSCRIBED AND SWORN to before me, this ___ day of______________ 201___
in_______________________________________, affiant exhibiting his/her Community tax
Certificate No.__________ issued at ____________________ on____________________.

__________________________
Notary Public

Doc No._______
Page No.______
Book No.______
Series of 201___