Form Amsa 250 - Multimodal Dangerous Goods Form


This form meets the requirements of SOLAS 74 Chapter VII regulation 4 and MARPOL 73/78 Annex
III regulation 4.
Note: When this form is used as a container/vehicle packing certificate only, not a combined
document, a dangerous goods declaration signed by the shipper or supplier must have been
issued/received to cover each dangerous goods consignment packed in the container.
The container/vehicle packing certificate is not required for tanks.
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1. Shipper/Consignor/Sender
2. Transport document number
4. Shipper‟s reference
3. Page
(page auto-numbers top right)
5. Freight forwarder‟s reference
24 hour contact number:
(1800 numbers not to be used)
6. Consignee
7. Carrier (to be completed by the carrier)
SHIPPER'S DECLARATION (refer to box 22 below)
I hereby declare that the contents of this consignment are fully and
accurately described below by the proper shipping name(s), and
are classified, packaged, marked and labelled/placarded, and are
in all respects in proper condition for transport according to the
applicable international and national governmental regulations.
8. This shipment is within the limitations prescribed for:
9. Additional handling information
10. Vessel and date
11. Port of loading
12. Port of discharge
13. Destination
NB: For Section 14 use Tab key to move across table and add more rows if needed - when data entry in Section 14 is complete,
use the DOWN ARROW key, or mouse pointer, to get to Section 15.
14. Shipping marks
No. and kind of packages; description of goods*
Gross Mass
Net Mass
* DANGEROUS GOODS: You must specify - UN number, proper shipping name, class or division and packing group (where
assigned) marine pollutant and observe the mandatory requirements under applicable national and international governmental
regulations. For the purposes of the IMDG Code see (see note 1 on notes page).
† For the purpose of the IMDG Code, see 5.4.2 (see also note 2 on notes page).
AMSA 250 (11/03)


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