Republic of the Philippines}
Province of Bohol}
City of Tagbilaran} S.S.
AFFIDAVIT OF LOSS
(Gov. Celestino Gallares Memorial Medical Center Employee Identification Card)
I, PATRICIA GRACE G. SUMAYLO, Filipino, of legal age, single, and a resident of
Poblacion, Panglao, Bohol, Philippines, after being duly sworn in accordance with law,
depose and state:
1. That I am a bonafide holder of a Gov. Celestino Gallares Memorial Medical Center
Employee Identification Card issued by the Gov. Celestino Gallares Memorial Medical
Center, Tagbilaran City;
2. That on August 10, 2024, my Gov. Celestino Gallares Memorial Medical Center
Employee Identification Card which was always in my possession, was lost and its
whereabouts cannot be ascertained despite due and diligent search made and undertaken such
that I now believe that the same is lost beyond recovery;
3. As such, I am executing this Affidavit of Loss to attest to the truth of the foregoing and to
support my application for the issuance of a new Gov. Celestino Gallares Memorial Medical
Center Employee Identification Card, in lieu of the one that was lost.
IN WITNESS WHEREOF, I have hereunto set my hand this __________________ in
Tagbilaran City, Bohol, Philippines.
PATRICIA GRACE G. SUMAYLO
Affiant
PRC (Nurse) ID NO: 0904874
SUBSCRIBED AND SWORN to before me this ____________________ in Tagbilaran
City, Bohol, Philippines.
Doc. No. _______
Page No. _______
Book No. _______
Series of 2024
