Amsa250 Multimodal Dangerous Goods Form

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MULTIMODAL 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.
Page 1 of 2
1. Shipper/Consignor/Sender
2. Transport document number
3. Page
of
pages
4. Shipper’s reference
(page auto-numbers top right)
5. Freight forwarder’s reference
24 hour contact number:
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
10. Vessel and date
11. Port of loading
12. Port of discharge
13. Destination
3
14. Shipping marks
No. and kind of packages; description of goods*
Gross Mass (kg)
Net Mass (kg) Cube (m
)
15. Container identification No./
16. Seal number(s)
17. Container/vehicle size & type 18. Tare mass (kg)
19. Total gross
Vehicle registration No.
(incl tare) (kg)
CONTAINER/VEHICLE PACKING CERTIFICATE
21. RECEIVING ORGANIZATION RECEIPT
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.
20. Name of company (see note 2 on notes page)
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 - 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 on notes page).
AMSA 250 (8/13)

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