FM-CMO-MMC-0211-09-01

REPUBLIC OF THE PHILIPPNES)

CITY OF ILOILO…………………)S.S.

ILLEGAL OR PROHIBITED DRUGS/SUBSTANCES AFFIDAVIT/DECLARATION

I, , Filipino, of legal age, with residence and postal address

at ________
, hereby depose and state that:
1. I have been hired as for the vessel by

(Name of Principal);

2. I hereby irrevocably confirm that:

a. I do not use and will not use illegal or prohibited drugs/substances.

b. I will not introduce illegal or prohibited drugs/substances on board the vessel.

3. I clearly understand the following:

a. Drug trafficking is a serious crime.

b. The Owners and the Master of the vessel will cooperate fully with the Public Authorities in
the criminal prosecution of anyone on board using and possessing illegal or prohibited drugs/substances
and/or paraphernalia for the use of illegal or prohibited drugs/substances.
c. I shall not be covered by the Owners P&I insurance should I commit any crime related to illegal or
prohibited drugs/substances.
d. I am personally responsible for all consequences (all costs, fines, charges, claims for damages, etc.) that
the Owners of the vessel may face or incur as a result of my committing a crime related to illegal or
prohibited drugs/substances.
e. Should I commit a crime involving illegal or prohibited drugs/substances, my contract of employment
shall be immediately cancelled and I shall pay and personally shoulder all repatriation costs, fines, etc.

4. I shall confirm that I have clearly read and fully understood this declaration.

Affiant

SUBSCRIBED AND SWORN to before me, on this day of , , Affiant exhibiting

to me his Passport No. , issued at , on .

Doc. No. ;
Page No. ;
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Series of 20 .