Form Amsa 250 - Multimodal Dangerous Goods Form - 2003
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2MULTIMODAL 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.
1 Shipper/Consignor/Sender
2 Transport document number
4 Shipper's reference
3
Page
of
pages
24 hour contact number:
5 Freight forwarder's reference
(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
Passenger and Cargo Aircraft / Cargo Aircraft Only
(delete non-applicable)
10 Vessel and date
11 Port of loading
12 Port of discharge
13 Destination
14 Shipping marks
No. and kind of packages; description of goods*
Gross Mass (kg)
Net Mass (kg)
Cube (m
3
)
18 Tare mass
19 Total gross
16 Seal number(s)
17 Container/vehicle size & type
15 Container identification
(kg)
(incl. tare) (kg)
No./ vehicle registration No.
21 RECEIVING ORGANIZATION RECEIPT
CONTAINER/VEHICLE PACKING CERTIFICATE
Received the above number of packages/containers/trailers in apparent
I hereby declare that the goods described above have
good order and condition unless stated hereon.
been packed/loaded into the container/vehicle identified
Receiving organization remarks :
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
22 Name of company
20 Name of company (see note 2 on notes page)
(of shipper preparing this note)
Name/status of declarant
Vehicle reg. No.
Name/status of declarant
Signature and date
Place and date
Place and date
Signature of declarant
DRIVER'S SIGNATURE
Signature of declarant
* 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 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 notes page)
AMSA 250 (11/03)
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