GRIPSHOLM SHIPPING S.A.

SHIP MANAGEMENT

WAIVER

In consideration of GRIPSHOLM SHIPPING S.A.s grant of permission to the undersigned to

sail aboard the M/V
____________________________________________________________
as a non-paying guest, the undersigned hereby waives all right to compensation from
GRIPSHOLM SHIPPING S.A., its servants and agents for loss of life or injury to the
undersigned or for damage to or loss of the undersigneds property or for any expense
incurred by the undersigned, any of which loss, injury, damage or expense shall be a
consequence of the undersigneds passage aboard the vessel, regardless of whether such
loss, injury, damage or expense is caused by the negligence or other act of GRIPSHOLM
SHIPPING S.A., its servants or its agents. The undersigned agrees that this waiver shall
extend to any rights that his representative may have as a result of such loss, injury,
damage or expense.

Date :

____________________________________________________

Full name :

____________________________________________________

Place and date of birth : ____________________________________________________

Signature :

____________________________________________________

1 Copy - GRIPSHOLM SHIPPING S.A. ; 1 Copy - Passenger ; 1 Copy - Ships File No. 9

GRIP FORM - 02