Imo Dangerous Goods Declaration Form
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1IMO DANGEROUS GOODS DECLARATION
1 Shipper
2 Transportation Document Number
3
4 Shipper’s Reference
1
1
PAGE
of
6 Consignee
5 Freight Forwarder’s Reference
7 Carrier (to be declared by the Carrier)
8 SHIPPER’S DECLARATION
I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name(s), and are classified, packaged, marked and
labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations.
10 Vessel/Flight and Date
11 Port/Place of Loading
9 Additional Handling Information
12 Port/Place of Discharge
13 Destination
14 Shipping Marks
Number and Kind of Packages, Description of Goods
GW (kg)
Net Mass (kg) Cube (m3)
15 CTU ID No.
16 Seal Numbers
17 CTU Size and Type
18 Tare Mass (kg)
19 Total Gross Mass (kg)
CONTAINER/VEHICLE PACKING CERTIFICATE
21 Receiving Organization Receipt
I hereby declare that the goods described above have
Received the above number of packages/containers/trailers in apparent good order and condition, unless
been packed/loaded into the container/vehicle identified
stated hereon; RECEIVING ORGANIZATION REMARKS:
above in accordance with the applicable provisions of
IMDG code 5.4.2. Must bE coMPlEtED AnD sIGnED
for All contAInEr/vEhIclE loADs by PErson
rEsPonsIblE for PAckInG/loADInG.
20 Name of Company
Hauler’s Name
22 Name of Company Preparing Note
Name/Status of Declarant
Vehicle Registration No.
Name/Status of Declarant
Place and Date
Driver Name and Date
Place and Date
Signature of Declarant
Driver’s Signature
Signature of Declarant
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Parent category: Financial