Appendix 1

(Sample - for reference only) Appendix I

Receipt for Reimbursement of Processing Fees

I, , ID / Passport No. , acknowledge receipt of the reimbursement of processing fees from my employer on (date) *in cash / by

cheque/ by bank autopay.

(a) Mandatory Insurance	$
(b) Medical Examination Fee	$
(c) Notarization Fee	$
(d) Visa Fee	$
(e) Philippines Overseas Employment Administration (POEA) Fee	$
(f) Others	$

* delete where appropriate