RETURN SERVICE AGREEMENT This Return Service Agreement made and executed this _____day of _______in _______, Philippines

by and between:____ !ame of Student"_____, #ilipino, of legal age, single$married to _______________, with residence and postal address to ______________________ hereinafter referred to as %Student%& and assisted by __ !ame of Parent$'uardian", #ilipino, of legal age, single$married to________________ with residence and postal address at _____________________________, hereinafter referred to a Parent/Guardian; ( and ( The UNIVERSITY OF THE PHILIPPINES, the national university of the Philippines, a public and secular institution of higher learning, created by virtue of Act !o) *+,-, as amended and reorgani.ed and operating by virtue of Republic Act !o) /0--, through its constituent university, 1niversity of the Philippines 2anila, with office address at +$# right 3entral 4loc5, Philippine 'eneral 6ospital, 2anila, represented herein by its 3hancellor, DR. MANUEL . AGULTO , hereinafter referred to as the UPM; !ITNESSETH" T#at 768R8AS, the RSA Policy of the 1P2 hereinafter referred to as the P$%i&' strives to ensure excellence and leadership in community(oriented health science education, research and service, using the primary health care approach, intended especially for the underserved& 768R8AS, the Student is covered under the P$%i&' and is aware of the re9uirement of the same& 768R8AS, the RSA becomes effective only upon acceptance of the Student to the said 3ollege& 768R8AS, in consideration of his$her admission to the 1P2 3ollege of _________ and his$her being covered under the abovementioned P$%i&' and considering his$her availment of state subsidy for his$her tuition and other fees, the Student is thus re9uired by 1P2 3ollege of ____________ to render health care services in the Philippines, within 0 years after his$her graduation&

NO!( THEREFORE, the foregoing premises considered, the Parties hereto hereby agree as follows: Arti&%e )" O*%i+ati$n, $- t#e Student The Student( having been accepted to the 1P2 3ollege of __________________ and covered by$under the RSA Policy, shall: 1. #aithfully adhere to the :ision(2ission of the 1P2 3ollege of ________ specifically the ideals and re9uirements of his$her academic program&

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2. Abide by the prescribed course of instruction unless sooner separated or dismissed

by competent authority for failure to cope with the academic and$or disciplinary standards, rules and regulations& 3. Render health care services in the Philippines for a minimum of two ;" years within five 0" years from graduation unless unable to do so due to physical and$or mental incapacities as determined by 1P2 3ollege of _______ authority& 4. Submit on or before <ecember =* of every year for five 0" years, beginning the year he$she graduated from 1P2 3ollege of _______, a report of his$her health care activities and services for that year, specifying the following minimum re9uired information: *" exact location and address where he$she is currently wor5ing and email address, phone$cellphone number, ;" nature of his$her wor5, =" the community served, and >" career plans$goal for the succeeding year) Arti&%e ." Pena%t' -$r rea&# $- O*%i+ati$n 1. The Student ac5nowledges and agrees that before the completion of his$her obligations under Article * of this Agreement and such other obligations as may from time to time be imposed by concerned 1niversity officials in the implementation of said Agreement, his$her transcript of records shall bear the statement "Has not complied with the return service obligation policy. For local employment only."
2. ?n addition, the Student shall be held liable for breach of contract @ointly and

severally with his$her parent$guardians, and surety, as provided for in the Suretyship Agreement hereto attached as Anne/ A and reimburse to 1P2 3ollege of _____ twice the full amount of his$her tuition, government subsidy and scholarship, and all other expenses incurred by 1P2 3ollege of _____, in connection with and$or as an incident of the Student,0 admission to the 1P2 3ollege of ______ with interest at the prevailing legal rate from the time of entry less the total amount of tuition fee paid in the event that he$she fails to fulfill the above mentioned obligations in paragraphs = and > of Article *, for no @ustifiable reason as determined solely 1P2 3ollege of ______ authority Arti&%e 1" Free and H$%d Har2%e,, C%au,e Any loss and$or damage caused by the Student to any person as a result of or in connection with his$her performance of health care services as re9uired under this Return Service Agreement shall be the sole and exclusive liability and responsibility of the Student and his$her parent$guardian) ?n this connection, the Student$Parent$'uardian holds 1P2 3ollege of _____ free and harmless from all claims, liabilities, proceedings, damages, costs, charges and expenses whatsoever arising out of or as a result of such loss and$or damage) Arti&%e 3" A%ternati4e Di,5ute Re,$%uti$n ?n case of a dispute between the Parties arising from the breach by the Student of his$her obligations under this Return Service Agreement, they hereby agree to freely and voluntarily submit themselves to the necessary consultation and negotiation process for
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purposes of amicably settling their dispute) Should the Parties fail to reach an amicable settlement, any dispute or controversy arising from this Agreement shall be submitted to arbitration, in accordance with the law RA /;+0") #inally, the Parties agree that should their dispute reach the courts of law, the competent courts of 2anila shall have exclusive @urisdiction over the same) IN !ITNESS !HEREOF, the Parties hereto hereby sign this Return Service Agreement together with the parent s"$guardian s" of the Student, this _____ day of _______ at _______________, Philippines) ________________________________ ____________________________ !ame and Signature of Student MANUEL . AGULTO( MD 3hancellor, 1P 2anila _________________________________ !ame and Signature of Parent$'uardian Signed in the presence of: __________________________ 1P 2anila Registrar ______________________________ <ean, 1P2 3ollege of _____________

Republic of the Philippines" 3ity of 2anila " S)S) AC6NO!LEDGMENT 48#AR8 28, a !otary Public for and in the 3ity of 2anila, Philippines, personally appeared 3hancellor 2anuel 4) Agulto and _______________________and ____________________ who exhibited to me their competent proof of identities indicated below: NAME GOVERNMENT ISSUANCE DETAIL ISSUED ID 2anuel 4) Agulto *,---,0; 1P 2anila ?<$;- Banuary ;--/ ______________________ ____________ _____________________ ______________________ ____________ _____________________ and who 5nown to me to be the same persons who executed the foregoing instrument and ac5nowledged to me that the same is their free and voluntary act and deed and that of the institutions they respectively represent)

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This instrument refers to Return Service Agreement consisting of four >" pages, including this page wherein this Ac5nowledgment is written and signed by the Parties and their instrumental witnesses) 7?T!8SS 2C 6A!< A!< !ATAR?AD S8AD, on the date and place first mentioned) <oc) !o) ___& Page !o) ___& 4oo5 !o) ___& Series of ;-*=

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