MULTIMODAL DANGEROUS GOODS FORM

This form may be used as a dangerous goods declaration as it meets the requirements of SOLAS 74, chapter VII, regulation 54; MARPOL 79/78, Annex III, regulation 4.

1 Shipper/Consignor/Sender

2 Transport document number
 

3 Page 1 of        pages
 

4 Shipper's reference

 

5 Freight forwarder's reference
 

6 Consignee

7 Carrier (to be completed by the carrier)
 

 

SHIPPER'S DECLARATION
  I hereby declare that the contents of this consignment are fully and accurately described below by the Proper Shipping Name, and are classified, packaged, marked and labeled/placarded and are in all respects in proper condition for transport according to the applicable international and national government regulations.

8 This shipment is within the limitations prescribed for:
      (Delete non-applicable)

9 Additional handling information

PASSENGER AND CARGO
  AIRCRAFT

CARGO AIRCRAFT
  ONLY

10 Vessel/flight No. and date
 

11 Port/place of loading

12 Port/place of discharge

13 Destination
 

14 Shipping marks     Number and kind of packages; description of goods     Gross mass (kg)       Net mass (kg)            Cube (m^3)

 

 

 

 

15 Container identification No./vehicle registration. No.
 

16 Seal number(s)

17 Container/vehicle & type

18 Tare mass (kg)

19 Total gross mass (including tare) (kg)

CONTAINER/VEHICLE PACKING CERTIFICATE
  
I hereby declare that the goods described above have been packed/loaded into the container/vehicle identified above in accordance with the applicable provisions.+
MUST BE COMPLETED AND SIGNED FOR ALL CONTAINER/VEHICLE LOADS BY PERSON RESPONSIBLE FOR PACKING/LOADING

21 RECEIVING ORGANIZATION RECEIPT
 
  Received the above number of packages/containers/trailers in apparent good order and condition, unless stated hereon: RECEIVING ORGANIZATION REMARKS:

20 Name of company

 

Haulier's name

Vehicle reg. no.

Signature and date

22 Name of company (OF SHIPPER PREPARING THIS NOTE)

Name/status of declarant
 

Name/status of declarant

Place and date
 

Place and date

Signature of declarant
 

DRIVER'S SIGNATURE

Signature of declarant

DANGEROUS GOODS:
You must specify: Proper Shipping Name, hazard class, UN No., packing group, (where assigned) marine pollutant and observe the mandatory requirements under applicable national and international government regulations.  For the purposes of the IMDG Code se 5.4.1.1
  
 + For the purposes of the IMDG Code, see 5.4.2.