Multimodal Dangerous Goods Form
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1
2MULTIMODAL DANGEROUS GOODS FORM
This form may be used as a dangerous goods declaration as it meets the requirements of SOLAS 74, chapter VII, regulation 5; MARPOL
73/78 Annex III, regulation 4
2 Transport document number
1 Shipper/Consignor/Sender
3 Page
of
page
4 Shipper's reference
235661
5 Freight forwarder's reference
7 Carrier (to be completed by the carrier)
6 Consignee
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 labelled/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:
9 Additional handling information
(Delete non-applicable)
Emergency response :
PASSENGER AND CARGO
CARGO AIRCRAFT ONLY
AIRCRAFT
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 (m3)
15 Container identification No./
16 Seal number(s)
17 Container/vehicle size
18 Tare mass (Kg)
19 Total gross mass
vehicle registration No.
& type
(including tare) (Kg)
CONTAINER/VEHICLE PACKING CERTIFICATE
21 RECEIVING ORGANIZATION RECEIPT
I hereby declare that the goods described above have been
Received the above number of packages/containers/trailers in apparent good
packed/loaded into the container/vehicle identified above in accordance
order and condition, unless stated hereon: RECEIVING ORGANIZATION
whit the applicable provisions.+
REMARKS:
MUST BE COMPLETED AND SIGNED FOR ALL CONTAINER/VEHICLE
LOADS BY PERSON RESPONSIBLE FOR PACKING/LOADING
20 Name of company
Haulier's name
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
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 governmental regulations. For the purposes of IMDG Code see 5.4.1.1..
+ For the purposes of the IMDG Code, see 5.4.2..
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