I hereby pledge that all the information I have supplied is true and correct and hereby DECLARE that I am in good health to participate in this program. I also hereby waive, exempt & release Emzor Pharmaceuticals Industries Limited or its subsidiaries or affiliates from any liability that may arise by virtue of my participation in this program. My unqualified acceptance & agreement to the rules & regulation/terms & condition of participation is evidenced by my Signature and my acts of completion and return of this Form to the program organizers.

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