ENVIRONMENT, HEALTH & SAFETY TERMS & CONDITIONS

ACKNOWLEDGEMENT STATEMENT
This letter confirms that an authorized representative of our company has read and understands the
contents of this " EHS 7.4/02 EHS Standard for contractors, EHS Request for quotation and Critical
to safety document. This letter shall also confirm that the obligation to safety and health is not
limited to the contents of the above document. All rules, regulations, and guidelines necessary to
provide a safe and healthful working environment for all employees will be always enforced.

Our company will comply with the Guidelines when employed by Siemens Healthineers Private
Limited (SHPL) and will have them sign and submit a copy of this "Acknowledgement Statement"
as proof that they fully understand the contents and implement the requirements at the project site.

(Name of Contractor)

(Address)

(Name of Deciding Authority/ Managing Director/ Officer)

(Signature of Deciding Authority/ Managing Director/ Officer)

(Title)

(Date)

If Corporation, affix seal and validation.