Republic of the Philippines BULACAN STATE UNIVERSITY Malolos Bulacan WAIVER

I, Guian Carla Alfonso Gutierrez of legal age, Filipino, single and with residence and

postal address at 33E Pio Cruzcosa, Calumpit, Bulacan, through the request of the Bulacan State University and Landbank of the Philippines in consideration thereof, hereby freely and voluntarily
assume and impose upon myself the following duties:

That I recognize the authority of the Landbank of the Philippines under whom I am placed and submit myself to rules and regulations that maybe imposed in connection with my training; That I assume fully responsibility to all damages incurred by me arising out of and in course of my training during hours; Furthermore, I renounce and waive all claims against Bulacan State University and Landbank of the Philippines for any injury that may sustain or any loss that I suffer, personal or pecuniary, in the performance of my duties or functions. Signed at Malolos, Bulacan this __day of ______ _2011.

_________________________ Affiant WITNESS: ______________________________ ______________________________

CONFIRMATION That we _________________________________________ of legal age, Filipino and a resident of ____________________________________________________ after being duly sworn in accordance with law hereby agree and state: That we hereby confirm the above waiver appearing in this instrument.

___________________________________ Signature of Parents/Guardian

SUBSCRIBED AND SWORN to before me in the City of Malolos, Province of Bulacan, this __th day of ________ 2011 by affiant exhibiting his/her certificate
No.__________________issued at _____________________________ on __________________.

_______________________________ (Administering Officer) DOC. NO. ________________ PAGE NO. _______________ BOOK NO. ______________

SERIES OF ______________