Ship's Name: ___________________________ Date: _____________________________

The undersigned do hereby declare to have read and understood the duties and responsibilities; the Quality Policy, the Safety and Environmental Protection Policy, the drug and alcohol policy and relevant Service Regulations of the QSMS. The undersigned will exercise due diligence to comply with these policy and the said regulations. The undersigned accepts (without objections) to follow the unannounced alcohol or/and drug testing in accordance with principles established in the company's QSMS when required by the Company or the Charterer, and also accept a search to be held in his cabin or among his personal effects when required by the Port States Authorities. The undersigned, are aware of their/emergency station and duties with respect to contingency situation; shall follow the Company's main rules, regulations & post requirements and shall carry out their duties and responsibilities as well as which assigned by the Master.
S/N	Name	Rank	Signature	S/N	Name	Rank	Signature

Fleet Personal Manager: ____________________________

Note: To be completed in Personnel Dept. before joining the ship and filed in office files.

To retain for 5 years.

Issue date: 03.11.2003/Rev. 00 PBO-PD01-F04 Page: 1/1

DECLARATION

QSMS PBO-PD01-F04 Rev. No.00

---