GRIPSHOLM SHIPPING S.A.

SHIP MANAGEMENT

INVENTORY OF MEDICAL LOCKER

M/V ____________________________ Date : ______________________

Part 1: MEDICINES

Code Description Stock o / b Expiry date

Page 1 of 3

To be submitted twice a year (June/December)

1 Copy - GRIPSHOLM SHIPPING S.A. ; GRIP FORM -
68
1 Copy - Ships Dispensary ; 1 Copy - Ships File No. 17;
Code Description Stock o / b Expiry date

Page 2 of 3
To be submitted twice a year (June/December)
1 Copy - GRIPSHOLM SHIPPING S.A. ; GRIP FORM
- 68
1 Copy - Ships Dispensary ; 1 Copy - Ships File No. 17;
Code Description Stock o / b Expiry date

__________________________ ________________________
Master Ch. Officer

To be submitted twice a year (June/December)

1 Copy - GRIPSHOLM SHIPPING S.A. ; GRIP FORM
- 68
1 Copy - Ships Dispensary ; 1 Copy - Ships File No. 17;
 Page 3 of 3

To be submitted twice a year (June/December)

1 Copy - GRIPSHOLM SHIPPING S.A. ; GRIP FORM
- 68
1 Copy - Ships Dispensary ; 1 Copy - Ships File No. 17;