Imo Dangerous Goods Declaration printable pdf download

IMO DANGEROUS GOODS DECLARATION

This form meets the requirements of SOLAS 74 chapter VII, regulation 5:

MARPOL 73/78 Annex III, regulation 5 and IMGD Code, General Introduction, section 9. Also meets NZMOT land transport requirements

SHIPPER (Name and Address)

REFERENCE NUMBER (S)

CONSIGNEE

CARRIER

COMPLETE THIS SECTION (5) FOR FCL CARGO ONLY. IN EITHER CONTAINERS OR VEHICLES

CONTAINER PACKING CERTIFICATE/VEHICLE DECLARATION

Name/status, company/

Organisation of signatory

Consolidatiors must fill in a Container Packing Certificate for all cargo

units containing packaged dangerous goods.

DECLARATION

Place and date

It is declared that the packing of the container/vehicle has been carried

out in accordance with the IMDG Code Amendment 30.

Refer to Part 5 consignment procedures section 5.4.2

Signature on behalf of packer

SHIPS NAME AND VOYAGE No.

PORT OF LOADING

CONTAINER No./TANK No. OR WAGON No

PORT OF DISCHARGE

(a) MARKS & Nos.

(b) NUMBER & KIND OF PACKAGES

(c.) GROSS MASS

(d)

GOODS

if applicable, identification

(kg); NET

DELIVERED

or registration number(s)

quantity/mass **

AS:

of the unit

Breakbulk

cargo

Unitised

cargo

Bulk

packages

Type of unit

(container

trailer, tank

vehicle, etc)

Open

(e.) UN Number

(f) PROPER SHIPPING NAME/CORRECT TECHNICAL NAME*

(g) IMO/HAZARD CLASS/DIVISION

Closed

(h) PACKING GROUP

(i) MARINE POLLUTANT**

(j) FLASHPOINT Deg C cc**

(k) HAZCHEM No.

Insert "x" in

appropriate box

(l)CONTROL & EMERGENCY

(M) EMS No. AND MFAG TABLE No.***

(N) TRADE NAME

TEMPERATURES **

TEMPERATURES

Note if applicable:

(1) the word "WASTE" should precede the name;

(2) "EMPTY UNCLEANED" or RESIDUE-LAST CONTAINED" should be added;

(3) "LIMITED QUANTITY" should be added

*Proprietary/trade names alone are not sufficient.

**When required in 9.3 of the General Introduction to the IMDG Code;

***When required and if know by shipper otherwise completed by shipping company.

Shaded areas in section 9 are the only information in that section required for land transport. All information must be completed for maritime transport.

ADDITIONAL INFORMATION

In certain circumstances special information/certificates are required, see DG Code, General Introduction, paragraphs 9.7.1/9.7.2

EMERGENCY INFORMATION

EMERGENCY NUMBER:

EMERGENCY NAME:

DECLARATION

Name/status.company/organisation of signatory

I hereby declare that the contents of this consignment are fully and accurately

described above by the correct technical names(s) (proper shipping names(s)),

and are classified, packaged, marked & labelled/placarded, and are in all respects

Place and Date

in the proper condition for transport according to the applicable International and

National Government regulations

Signature on behalf of shipper

Imo Dangerous Goods Declaration

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