Country of ________________)

City of ___________________) S.S.

READ THIS WARNING!

Any applicant who knowingly makes
any false statement herein shall be
subject to the provisions of Sec.
13, Art. III of R.A. No. 9266, known
as the Architecture Act of 2004,
and Sec. 13 Rule III of Board Res.
No. 07, Series of 2004, known as the
IRR of the Architecture Act of
2004, without prejudice to criminal
prosecution if the evidence warrants
under R.A. No. 9266 and the Revised
Penal Code, among other subsisting
statutes.

SPECIAL AFFIDAVIT
(for Prospective Examinees who Acquired Experience Under Mentors
other than Filipino Mentor-Registered and Licensed Architects
(RLAs), in compliance with PRBoA Resolution No. 2007-06, Series of
2007 dated 13 November 2006)

I, _______________________________________ of legal age, with

residence and postal address at _________________________________,
after being duly sworn upon my oath, depose and state:
1. That I am a practicing Philippine registered and licensed
architect (RLA) with PRC Certificate of Registration No.
_________ issued on ____________________ and presently with
office/s located at ________________________________________
(and at ___________________________________________);

2. That my area of professional architectural practice is in

____________________________ (and in ______________________),
and that I have performed such services in the city
(town)/country of ___________/__________ over the years
_______ through ____________ (and in the city(town)/country of
_______________ over the years ______ through ______);

3. That I have known Mr./Mrs. ______________________________ (the

prospective examinee) to have undergone the equivalent of
Philippine Diversified Training under a non-Filipino architect
(or other construction industry-related professional), in
undertaking architectural and allied architectural services
defined as part of the scope of an RLAs services as defined
under R.A. No. 9266, its IRR and derivative regulations, not
limited to the preparation of architectural deliverables/
outputs, over the period ______________ through
_______________________ (and from ______________________ to
__________________________), in the city (town)/ country of
__________________________________ (and in the city (town)/
country of __________________________________), respectively;

4. That I have known the prospective examinee over the period

________ through _______ (or a total number of months at
________) for the following reasons:
a) __________________________________________________________;
b) ______________________________________________________; and
c) __________________________________________________________;

5. That attached hereto is DT Form 002 (otherwise known as the

Logbook of Diversified Experience in Architecture or LDEA),
duly accomplished, marked as Annex A and made an integral
part hereof;
 6. That I am willing to appear before the Professional Regulatory
Board of Architecture (PRBoA), the Professional Regulation
Commission (PRC), or its duly authorized representative/s, and
present satisfactory evidence attesting to my knowledge of the
diversified experience acquired by the prospective examinee,
if and when required; and

7. That I undertake full and unconditional responsibility for any

and all statements made in this affidavit and in the LDEA and
am fully aware that any fraudulent statements or
misrepresentation may constitute sufficient grounds for the
filing of an administrative complaint at the PRC, where the
penalty if adjudged guilty, is the revocation of my PRC
certificate of registration and license.

IN TRUTH OF ALL THE FOREGOING, I have signed this affidavit

this ____ day of __________ 200_ at ____________________________.

AFFIANT
(must be a Filipino RLA who must affix
his/her dry seal and who must attach a
valid PRC registration certificate, a
valid identification card and a valid
IAPOA Certificate & Official Receipt)

SUBSCRIBED AND SWORN TO before me this ______ day of ______

200__ at _________________, affiant exhibiting to me his/her
Community Tax Certificate No. ________ issued on _______ at
________(or his/ her Passport with No. ___________).

NOTARY PUBLIC/ CONSUL/

(or other duly designated/
empowered Philippine Government
Officials)
Until December 31, __________

Doc. No. _________

Page No. _________
Book No. _________
Series of _________