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Multimodal Dangerous Goods Form

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MULTIMODAL DANGEROUS GOODS FORM

This form may be used as a dangerous goods declaration as it meets the requirements of SOLAS 74, chapter VII, regulation 4; MARPOL 73/78, Annex III,

regulation 4.

2 Transport document number

1 Shipper / Consignor / Sender

3 Page 1 of

pages

4 Shipper’s reference

5 Freight forwarder’s reference

6 Carrier of cargo

8 SHIPPER’S DECLARATION

7 Consignee

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/placarded

and are in all respects in proper condition for transport according to the applicable international

and national government regulations.

9 This shipment is within the limitations prescribed for

10 Additional handling information

(Mark applicable option if any)

PASSENGER AND CARGO AIRCRAFT

CARGO AIRCRAFT ONLY

11 Vessel / flight no. and date

12 Port / place of loading

13 Port / place of discharge

14 Destination

15 Marks &

Proper shipping name,

Gross

Net

Cubic

Emergency

IMO

Ems

m 3

numbers

description of goods, nbr. and

weight (

)

weight (

)

meters(

)

phone number

Code

Class

type of packages / units

16 Container identification No.

1 7 Seal number(s)

1 8 Container / vehicle

19 Tare weight (kg)

20 Total gross weight (including tare) (kg)

& type

Vehicle registration No.

30 Name of company (OF SHIPPER

CONTAINER / VEHICLE PACKING CERTIFICATE

25 RECEIVING ORGANIZATION RECEIPT

PREPARING THIS NOTE)

Received the above number of packages /

I hereby declare that the goods described above

have been packed / loaded into the container /

containers / trailers in apparent good order and

vehicle identified above in accordance with the

condition, unless stated hereon: RECEIVING

applicable

provisions. *

ORGANIZATION REMARKS:

MUST BE COMPLETED AND SIGNED FOR ALL

COUNTAINER / VEHICLE LOADS BY PERSON

RESPONSIBLE FOR PACKING / LOADING

21 Name of company

26 Haulier’s name

22 Name / status of declarant

27 Vehicle registration no.

31 Name / status of declarant

23 Place and date

28 Signature and date

32 Place and date

24 Signature of declarant

29 DRIVER’S SIGNATURE

33 Signature of declarant

For the purposes of the IMDG Code see

5.4.1.4. *

For the purpose of the IMDG Code, see 5.4.2.

Multimodal Dangerous Goods Form

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