Multimodal Dangerous Goods Form

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Multimodal Dangerous Goods Form
1 Shipper/Consignor/Sender (full style address is mandatory)
2 Transport document number
4 Shipper's reference
5 Freight Forwarder's reference
6 Consignee
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 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
PASSENGER AND CARGO
CARGO ONLY
10 Vessel and Voyage number
11 Port of loading
12 Port of discharge
13 Destination
14 Shipping Marks *Number and kind of packages; description of goods
Gross mass (kg)
Net Mass
Cube(m3)
Proper Shipping Name
:
Technical name
:
Packaging type (Outer ) with quantity
:
(if outer packing is cartons it is mandatory to specify number & type of
inner packing)
Packaging type (Inner ) with quantity :
IMO class
:
UN number
:
Packaging group
:
Marine Pollutant
:
Sub risk (if any) :
Flashpoint :
EMS Code
:
IMO Label
:
MFAG Number:
Emergency Contact person name/number
:
Limited Quantity :
Poisonous inhalation hazard :
Notes :
*Fields marked in red are mandatory to fill. Rest as per conditions if amy required.
Total cube (m3)
Other Details
15 Container identification
no.
16 Seal number(s)
17 Container size & type
18 Tare mass (kg)
19 Total gross (incl. tare) (kg)
CONTAINER 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 order
placed/loaded into the container/vehicle identified above in accordance
and condition, unless stated hereon: RECEIVING ORGANIZATION RE-MARKS:
with the applicable provisions. **MUST BE COMPLETED AND
SIGNED FOR ALL CONTAINER/VEHICLE LOADS BY PERSON
RESPONSIBLE FOR PACKING/LOADING
20 Name of company(stamp & signature are mandatory)
Haulier's name
22 Name of company (OF SHIPPER PREPARING
THIS NOTE) (stamp & signature are mandatory)
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., Packaging group, (where assigned) Marine pollutant and observe the mandatory
requirements, under applicable national and international governmental regulations. For the purpose of the IMDG Code see
5.4.1.
** For the purpose of the IMDG Code see 5.4.2.

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