BML Form 2-C

U,P. MARINE SCIENCE INSTITUTEIndemniW and Wa.lver Form

I,of---in *^tdrratXn of ine U.P. Marine Science Institute (hereinafter refewed to as "the Itutitute" which

expression shall when the context admits or requires be deemed to include its fficers and agents)

HEREBY AGREE as follow.r :

1. I HiiREBy KELEASE AND FOREVER DISCHARGE the Institutefrom all actions,

proceedings, suits, costs, claims and demands which I might have or but for the signing of this-agreement

might have had against the Institute Jbr any loss, damage or iniury 6ncludingdiath) of u,haisoever nature and howsoever, arising in connection with or arising out a/'my

voluntary engagement with or workingfor the Institute whether caused by any act or omission

of the Institute or the negligence, default or miscanduct of the Institute or otherwise

. howsoever.

2. I HEREBY INDEMNIFY AND AGREE TO KEEP INDEMNIFIED thc InStiTUICfTOM ANQ

agairct all actions, proceedings, suits, costs, claim"v and demands and the cost reasonably

incurred in defending or resi,sting the sarne whiclt m.ay hereafter he made by any per,son orpersons in respect of any strch loss, damage or injury Qncluding death) as qfqresaid'

DATED this _day oJ'-*-, 20-.

Signcture

NAITURE OF ACTIVITY:

PARTICULARS IN CASE OF EMERGENCY:

Full name:Address & Phone No.:Next of kin:Relationship of next of kin:Address & Phone No. of next of Hn:

I 6 Jun 2003