I, ______, of legal age, single/married, and residing at ______, after having been duly sworn to according to law, hereby depose and state:

           1. That I am an employee of _____, having connected therewith as _____, since ________;

           2. That I have a letter of resignation with the company effective ________;

           3. That I hereby relieve and discharge said (name of company) and its officers from any and all claims by way of unpaid wages, separation pay, overtime pay, 13th month pay or otherwise as may be due me or incident to my employment with said company;

           4. That I hereby state further that I have no claim, right or action of whatsoever nature, whether past, present or contingent, against said company and its officers;

           5. That the contents of this document, although prepared in English, was interpreted and explained to me in Pilipino by the undersigned Personnel Officer and the same is therefore understood by me;

           6. That I am executing this instrument freely and voluntarily without any moral or physical threat, coercion or promise of reward in any form.

           IN WITNESS WHEREOF, I hereby affixed my signature this ___ day of October, 2003 at the City of Makati, Philippines.