Form Amsa 250 - Multimodal Dangerous Goods Form (Page 2 of 3) in pdf

Form Amsa 250 - Multimodal Dangerous Goods Form Page 2

MULTIMODAL DANGEROUS GOODS FORM

Page 2 of 3

NB: For Section 15, 16, 17, 18, 19, use Tab key to move across table and add more rows if needed - when data entry in Section

15 to 19 is complete, use the DOWN ARROW key, or mouse pointer, to get to Section 20.

15. Container identification

16. Seal number(s) 17. Container/vehicle size &

18. Tare mass (kg) 19. Total gross (incl

No/Vehicle registration No

type

tare) (kg)

CONTAINER/VEHICLE PACKING

21. RECEIVING ORGANIZATION RECEIPT

CERTIFICATE

Received the above number of packages/containers/trailers in

I hereby declare that the goods described

apparent good order and condition unless stated hereon.

Receiving organization remarks:

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.

Haulier‟s name

20. Name of company (see note 2 on notes page)

22. Name of company

(of shipper preparing this note)

Name/status of declarant

Vehicle reg no.

Name/status of declarant

Place and date

Signature and date

Place and date

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 governmental regulations.

For the purposes of the IMDG Code see 5.4.1.4. (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)

Form Amsa 250 - Multimodal Dangerous Goods Form Page 2