Signed at Signed on Name (printed) & Signature of Owner / Charterer / (DD/MM/YY) Authorised Person Declaration Owner or other authorised person must complete this declaration; if person other than Owner or person in Part 4, please complete Declarant details. Full name of Declarant Relationship to Physical address Postal address Email Phone The Owner declares / The Declarant declares on behalf of the Owner/Charterer (Delete as appropriate): That the information given in this and all supporting documents are, to the best of my knowledge and belief, true and correct. That neither the nor the Beneficial owner is associated with any of the individuals or entities listed on the UN mandated Sanctions list found at: This Declaration shall be made before a Justice of the Peace, or a Commissioner for Oaths, Solicitor, Notary Public or the Registrar or Deputy Registrar of Ships of the Cook Islands Ships Registry or before any person authorised by law to administer oaths in the country where the declaration is made. Signature of Declarant / Date Signature and full name of Witness Occupation and address
Signed at Signed on (DD/MM/YY) Name (printed) & Signature of Owner / Charterer / Authorised Person Declaration Owner or other authorised person must complete this declaration; if person other than Owner or person in Part 4, please complete Declarant details. Full name of Declarant Relationship to Physical address Postal address Email Phone (Delete as appropriate): The Owner declares / The Declarant declares on behalf of the Owner/Charterer That the information given in this and all supporting documents are, to the best of my knowledge and belief, true and correct. That neither the nor the Beneficial owner is associated with any of the individuals or entities listed on the UN mandated Sanctions list found at: This Declaration shall be made before a Justice of the Peace, or a Commissioner for Oaths, Solicitor, Notary Public or the Registrar or Deputy Registrar of Ships of the Cook Islands Ships Registry or before any person authorised by law to administer oaths in the country where the declaration is made. Signature and full name of Witness Occupation and address Signature of Declarant / Date
07_E_F_CIYS_v9_2.01.docx