Multimodal Dangerous Goods Form

MULTIMODAL DANGEROUS GOODS FORM

This form maybe used as a dangerous good declaration as it meets the requirements of SOLAS 74, chapter regulation 4; MAROL 73/78,

Annex III, regulation 4.

1. Shipper/ Consignor/ Sender

2. Transport document number:

Shipper’s Reference no.:

3. Page 1 of

pages

5. Freight Forwarder’s Reference:

6. Consignee

7. Carrier (to be completed by carrier):

SHIPPERS 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 labeled/ placecard and are in all respects in proper

condition for transport according to the applicable international and national governments.

8. This shipment is within limitations prescribed for

9. Additional Handling Information

(Delete non-applicable)

PASSGENGER & CARGO

CARGO AIRCRAFT

AIRCRAFT

ONLY

10. Vessel/flight no and date

11. Port/ Place of Loading

11. Port/ Place of discharge

12. Destination

14. Shipping marks

*Number and kind of packages, description of goods

Gross mass (kg)

Net mass (kg)

Cube (m² )

Container identification No. /

16. Seal Number (s)

17. Container vehicle size and type

18. Tare mass (kg)

19. Total gross including tare (kg)

Vehicle registration No.

:

:

:

:

:

21. RECEIIVING ORGANIZATION RECEIPT

CONTAINER VEHICLE PACKING CERTIFICATE

I hereby declare that the goods described above have been

Received the above number of packages/ container/ trailers in apparent good order and

packaged/ loaded into the container/ vehicle identified above in

Condition, unless state hereon: RECEIVING ORGANIZATION REMARKS

accordance with the applicable provisions

MUST BE COMPLETED AND SIGNED FOR ALL

CONTAINER/VEHICLE LOADS BY PERSON

RESPONSIBLE FOR PACKING/ LOADING

Hauler’s Name:

20. Name of company

22. Name of company (shipper preparing this note)

Name/Status of Delclarant:

Vehicle registration No.:

Name/Status of Delcarant:

Signature and date

Place and date:

Place and date:

Signature of Declarant

Signature of Driver

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 purpose of the IMDG Code, see 5.4.1.4



For the purpose of the IMDG see 5.4.2