Date: {{$activationDate}}

Investigator’s Declaration

To,

Alkem Laboratories Ltd.

Mumbai

Dear Sir/Madam,

I, the undersigned, have read and understood this protocol titled {{$study_description}} and hereby agree to conduct the study in accordance with this protocol and to comply with all requirements regarding the obligations of investigators and all other pertinent requirements of applicable regulatory authorities.

I hereby agree to share my experience with Alkem and that shall have the unconstrained right to use it in perpetuity, in all forms of media including but not limited to print, audio, video, website, internet and such other media which is in existence for today in display, exhibition, broadcast, transmission, communication or any other media which may come into existence at a future date.

I shall maintain confidentiality of the identification of all participating subjects and assure security and confidentiality of study data.

I understand that Alkem shall have all rights to edit, reproduce, adapt, create derivative works or translate any information expressed by me as it deems fit, for the above-mentioned purpose, without my approval. I agree that this is not intended for any promotion or advertisement of any pharmaceutical product.

I am aware of and shall at all times abide by all the applicable laws governing medical professionals. I expressly release, its employees, representatives, agents etc. from and against any and all claims arising out of the uses herein granted, including without limitation any claims for libel or violation of any right of publicity or privacy.

I further agree to ensure that all associates assisting in the conduct of this study are well informed regarding their obligations and confirm to conduct this study under my direction