Owner/Principal Dentist Vice President For Academic Affairs

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DENTAPRIME DENTAL SERVICES POLYTECHNIC UNIVERSITY OF THE

PHILIPPINES

By: By:

_________________________________ ____________________________
DR. MARIA DOLORES ADRANEDA DR. MANUEL M. MUHI
Owner/Principal Dentist Vice President for Academic Affairs

SIGNED IN THE PRESENCE OF:

______________________________ ___________________________________
MS. MARICEL CANABA DR. JOHN MARK S. DISTOR, RPm
Clinic Coordinator Chairperson, Dept. of Psychology

___________________________________
DR. NICOLAS T. MALLARI, RPm
Dean, College of Social Sciences and Dev’t.

ACKNOWLEDGMENT

Republic of the Philippines)


City of _______________________)S.S.

BEFORE ME, a Notary Public, for and in the City of _______________, this _____day of
_______, 2017. Personally appeared:

Valid Proof of Identity Issued at/on


DR. MARIA DOLORES ADRANEDA ___________________ _________________

DR. MANUEL M. MUHI ___________________ _________________

Known to me to be the same persons who executed this instrument and acknowledged the
same to me as their free and voluntary act and deed, and of the entities they respectively
represent.

This document consists of three (3) pages including the page where this
Acknowledgement is written, and the parties signed at the left margin of each and every page
hereof.

WITNESS MY HAND AND SEAL on the place and date first above written.

Notary Public

Doc. No. _____;


Page No. _____;
Book No. ____;
Series of 2017

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