Transcription of MULTIMODAL DANGEROUS GOODS FORM - bss.hk
1 MULTIMODAL DANGEROUS GOODS FORMThis form may be used as a DANGEROUS GOODS declaration as it meets the requirements of SOLAS 74, chapter VII, regulation 54; MARPOL 79/78, Annex III,regulation Shipper/Consignor/Sender2 Transport document number3 Page 1 of _____ pages4 Shipper s reference5 Freight forwarder s reference7 Carrier (to be completed by the Carrier)6 ConsigneeSHIPPER S DECLARATION I herby declare that the contents of this consignement are fully and accurately describedbelow by the Proper Shipping Name, and are classified, packaged, marked and labeled/placardedand are in all respects in proper condition for transport according to the applicable internationaland national government This shipment is within the limitations prescribed for:(Delete non-applicable)9 Additional handling informationPASSENGER ANDCARGO AIRCRAFTCARGO AIRCRAFTONLY10 Vessel/flight no.
2 And date11 Port/place of loading12 Port/place of discharge13 Destination14 Shipping marksNumber and kind of packages; description of goodsGross mass (kg)Net mass (kg) Cube (m3)15 Container identification No. Vehicle registration Seal number(s)17 Container/vehicle & type18 Tare mass (kg)19 Total gross mass (including tare) (kg)CONTAINER / VEHICLE PACKINGCERTIFICATE I hereby declare that the GOODS described above havebeen packed/loaded into the container/vehicle identifiedabove in accordance with the applicable provisions.
3 +MUST BE COMPLETED AND SIGNED FOR ALLCOUNTAINER/VEHICLE LOADS BY PERSONRESPONSIBLE FOR PACKING/LOADING21 RECEIVING ORGANIZATION RECEIPT Received the above number of packages/containers/trailers in apparent good order andcondition, unless stated hereon: RECEIVING ORGANIZATION REMARKS:20 Name of companyName/status of declarantPlace and dateSignature of declarantDANGEROUS GOODSYou must specify: Proper Shipping Name, hazard class, UN No., packing group, (where assigned) marine pollutant and observe the mandatory requirements under applicablenational and international government regulations.
4 For the purposes of the IMDG Code see +For the purpose of the IMDG Code, see s nameVehicle registration and dateDRIVER S SIGNATURES ignature of declarant22 Name of company (OF SHIPPER PREPARING THIS NOTE)Name/status of declarantPlace and dateForm provided by Navigational Logistics, Inc. - DANGEROUS GOODS FORM1 Shipper/Consignor/Sender2 transport document number3 Page 1 of _____ pages4 Shipper s reference5 Freight forwarder s reference14 Shipping marksNumber and kind of packages; description of goodsGross mass (kg)Net mass (kg) Cube (m3)
