Drug and Alcohol Declaration at Sign On

Vessel:

Port:

Date:

I, the undersigned, confirm that I have read and understood the Maersk Tankers Drug and Alcohol Procedure
and the Drug and Alcohol Policy Statement to which it relates. I am aware of the consequences of being in
breach of the Maersk Tankers Drug and Alcohol Procedure and the Drug and Alcohol Policy Statement from
this point until I sign off from this vessel.

Ankit Paigwar

Crewmember Name Office Representative Name

Crewmember Signature Office Representative Signature