DECLARATION FORM

TO : RBM / ABM NAME ADDRESS/HQ: GSK

Dear Sir

I (Name) Employee No. working as MRlSE/ABM in Team (1/2/3/4/5/6) based at hereby acknowledge having purchased the helmet under the Company's scheme (enclosed is the cash receipt/invoice from the retailer) and claimed reimbursement of Rs . I confirm that I am aware of the Company's occupational travel policy guidelines and I will ensure that I use the Helmet at all times while travelling on a two wheeler motor vehicle (geared or ungeared). I understand that the Company has merely facilitated my using a Helmet for my own safety and I will not hold the Company responsible or iiabie for any injury/ permanent disability/ loss of life caused while travelling on a two wheeler motor vehicle when using the said helmet. In the event of my separation from the services of the company, within twelve months of the purchase of the helmet, I hereby agree that the cost of the said helmet may be deducted by the company from my final settlement.

Signed: Date: HQ: Witness: 1. Name 2. Name Signature Signature . . Year: Branch: