SPECIAL POWER OF ATTORNEY

I, ___________________________, Filipino, of legal age, with postal address at

_____________________________________________ hereby name, appoint and constitute
____________________________________________________________ to be my true and lawful attorneys, to act on
my behalf and in my name, to execute and perform all or any of the following acts, deeds, matters
and things, in connection with claim of disability/medical benefits and other pertinent allowances
in connection with my permanent disability to return to work, to wit:

1. To act as my legal representative to represent me before the administrative and

meetings with ____________________________________ (the “Company”), the Philippine
Department of Labor and Employment, the National Labor Relations Commission ,
and other government offices for the purpose of claiming my disability benefits;

2. To represent me before any and all government and private Offices/agencies in the
Philippines;

3. To bring suit, defend and enter into a compromise in my name and stead in litigation
brought for or against me in all matters involving my claim for medical benefits
against the Company.

HEREBY GIVING AND GRANTING unto our said attorney full powers and authority to do and
perform all and every act requisite or necessary to carry into effect the foregoing powers, as fully
to all intents and purposes as I might or could lawfully do if personally present, with full power of
substitution and revocation, and hereby ratifying and confirming all that my said attorney or his
substitute shall lawfully do or cause to be done by virtue hereof.

IN WITNESS WHEREOF, I have hereunto set my hand this _______________________, in __________________.

________________________________
Affiant

Signed in the presence of:

__________________________ __________________________

ACKNOWLEDGMENT