Multimodal Dangerous Goods Form

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.

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