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Republic of the Philippines)



I, SHANON BUNA DELOS SANTOS, of legal age, Filipino, and a resident of

_______________________________________________, after having been sworn in
accordance with law, state that:

1. On ______________, I voluntarily submitted my application for deployment

with Interorient Maritime Enterprises, Inc.

2. On ______________, while my application is pending, I sought the assistance

of Interorient Maritime Enterprises, Inc. and obtained a personal loan from it
in the amount of ____________ and without any interest.

3. I promised to pay Interorient Maritime Enterprises Inc. the sum of

__________ within ___ days from my deployment either through shipboard
deduction or through allotment deduction.

4. In connection therewith, I hereby authorize Interorient Maritime Enterprises,

Inc. to collect the entire amount from me or to immediately deduct the said
amount from my future salary without further notice to me.

5. In the event that my application is rejected or my deployment does not

materialize, for any reason whatsoever, I undertake to pay Interorient
Maritime Enterprise, Inc. my personal loan within thirty (30) days from the
withdrawal of my documents.

6. I hold Interorient Maritime Enterprises, Inc. free and harmless from any
liability that may arise as a result of my decision to withdraw my application
and to transfer to another manning agency.

7. Should I fail to pay my obligation, I undertake to indemnify Interorient

Maritime Enterprises, Inc. the costs that I will incur in collecting the amount
from me, including damages and attorney’s fees.

8. I understand that Interorient Maritime Enterprises, Inc. may proceed against

me at any Court of law and even before the POEA for misrepresentation.

IN WITNESS WHEREOF, I hereunto affix my signature this _______ at



SUBSCRIBED AND SWORN TO before me this ___________ at ______________,

affiant exhibiting to me his __________________ as his competent evidence of identity.

Doc No.
Page No.
Book No.
Series of 2017.