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I hereby declare under oath that:
1. This Data Sheet has been accomplished by me, and is a true, correct and complete statement
pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the
Philippines.
2. I have disclosed all information relevant to my application/appointment in a GOCC Governing
Board.
3. I have all the qualifications and none of the disqualifications of an Appointive Director.
4. Neither I nor any person or organization that I am affiliated with is engaged in any transaction
or activity that may represent a conflict with my possible appointment in a GOCC Board.
5. I will promptly inform the Governance Commission of any situation/affiliation/business relations
constituting and/or could give rise to a conflict of interest.
I HrR=ev wAtvE THE coNFlDENTtALtry oF THE tNFoRMATtoN oN THts Dnrn SHEer AND AUTHoRtzE THE
GCG ro rHoRoucHly TNVESTTcATE THE sAME tN RELATToN To My sutrABtlrry FoR GOCC
DIRECToRSHIP.
1211212M6LEONCIO B. EVASCO, JR.
Cabinet Secretary and PCA Chairman
MMIDD/YYYY SIGNATURE
SUBSCRIBED AND SWORN To BEFoRE ME,
EXHTBITED To ME (Hrs/H=n) Corvrrr,rur'trw Tax
ON AND BY
Corrruururrv Tnx CrnrrrrcRre No.
CrRrrrcRrE No.
WHO
TSSUED AT
WHO
ISSUED AT
EXHTBTTED ro ME (nrs/nrn)
ON
NOTARY PUBLIC
DOC. NO.
PAGE NO.
BOOK NO.
SERIES OF