DANGEROUS GOODS DECLARATION
This form meets the requirements of SOLAS 74 chapter VII, regulation 5; MARPOL 73/78 Annex III, regulation 4 and the
IMDG Code, chapter 5.4.
Consignor (name, address): / Reference Nbrs:Carrier:
Consignee (name, address): / Name/Status, company/organization of signatory:
Container packing certificate/vehicle declaration
DECLARATION / Place & Date:
It is hereby declared that the packing of goods into the unit
has been carried out in accordance with the provisions of 5.4.2.1 / Signature on behalf of consignor:
Ship's Name and Voy. #: / Port of Loading: / Special Instructions:
Port of Discharge: / Goods Delivered As: / Type of Unit & Unit Nbr.:
No Qty., Type & Kind of Dangerous goods decription*
Pkgs. Size / Mass/Volume/Cube
Additional Information:
DECLARATION
It is hereby declared that the contents of this consignment
are fully and accurately described above by the proper
shipping name(s) and are classified, packaged, marked / Name/status, company/organization or signatory:
and labeled/placarded, and are in all respects in proper
condition for transport according to applicable
international and governmental regulations. / Signature on behalf of consignor:
* The following shall be specified: UN No., Proper Shipping Name, hazard class, packing group (where assigned) and marine pollutant; additional information when appropriate shall be placed after the dangerous goods description. For the purposes of the IMDG Code see 5.4.1.4