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IMO Dangerous Goods Declaration

Signature on behalf of shipperName/status, company/organization of signatoryPlace and Date ConsigneeShipperThis form meets the requirement of SOLAS 74 chapter VII, regulation 5;MARPOL 73/78 ANNEX III, regulation 4 and the IMDG CODE, General introduction, section 9 IMO Dangerous Goods DECLARATIONR eference number(s)Page 1 of 1 Shipper's Reference NumberName/status, company/organization of signatoryContainer packing certificate/vehicle declarationDECLARATIONIt is declared that the packing of the container/vehicle has been carried out in accordance with the General Introduction, IMDG Code, paragraph BE COMPLETED FOR SHIPMENTS IN CONTAINERS OR VEHICLESM arks applicable, identification or registration number(s)of the UnitNumber and kind of packages, proper shipping name *, IMO hazard class/division, UN number, packaging group (where assigned) * *, flashpoint (in ) * *, control and emergency temperatures * *, identification of the good as MARINE POLLUTANT* *, EmS No. and MFAG Table No.

Signature on behalf of shipper Name/status, company/organization of signatory Place and Date Shipper Consignee This form meets the requirement of …

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