THIS IS TO CERTIFY THAT, the M/T :

Port of Registry :

Official number :

Gross Tons

was duly delivered/re-delivered by

to and accepted by

at location

on the

at

Hrs local time.

It was agreed that at

Hrs local time, on the

The vessel had bought the following:

MARINE GAS OIL :

MARINE DIESEL OIL :

MARINE FUEL OIL 500 CST :

LUBRICATION OIL :

FRESH WATER :

MASTER

CHIEF ENGINEER

(NAME/SIGNATURE/STAMP)

(NAME/SIGNATURE/STAMP)

OWNER'S AGENT

CHARTERER'S AGENT

(NAME/SIGNATURE)

(NAME/SIGNATURE)

SURVEYOR (if any)*

(NAME/SIGNATURE/STAMP)