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DG Declartion Format

This multimodal dangerous goods form can be used to declare dangerous goods by sea or land in accordance with international regulations. It includes fields to identify the shipper, consignee, description of goods including proper shipping name, UN number, class, hazard, packaging, and emergency contact details. The shipper's declaration section requires confirmation that the contents are properly described, classified, packaged, and labeled according to applicable national and international regulations.

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Pandit Aashish Bhardwaj
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800 views1 page

DG Declartion Format

This multimodal dangerous goods form can be used to declare dangerous goods by sea or land in accordance with international regulations. It includes fields to identify the shipper, consignee, description of goods including proper shipping name, UN number, class, hazard, packaging, and emergency contact details. The shipper's declaration section requires confirmation that the contents are properly described, classified, packaged, and labeled according to applicable national and international regulations.

Uploaded by

Pandit Aashish Bhardwaj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Multimodal Dangerous Goods Form

This form may be used as a dangerous goods declaration as it meets the requirements of Solas 74,chapter VII,
regulation 5; MARPOL 73/78, Annex III, regulation 4.

Error: Reference source not found1 2 Transport Document Number:


Shipper/Consignor/Sender :

3 Page of Page 4 Shipper's reference

5 Freight Forwarder's reference

6 Consignee :
NISSEI CORPORATION        
10-5, NIHONBASHI-HONCHO  SHIPPER'S DECLARATION
I hereby declare that the contents of this consignment are fully and
1-CHOME, CHUO-KU, TOKYO 1030023, JAPAN  accurately described below by the proper shipping name, and are
TEL: +81-3-3242-10207 FAX:81-3-3241-6748 classified, packaged, marked and labeled /placarded and are in all
respects in proper condition for transport according to the applicable
international and national government regulations.
9 Additional handling information

10 Vessel and date 11 Port of loading


PIPAVAV EMERGENCY CONTACT NUMBER 24HRS :

12 Port of discharge 13 Destination


YOKOHAMA YOKOHAMA EMERGENCY CONTACT PERSON 24HRS:

14 Shipping Marks *Number and kind of packages; description of goods Gross Net Total No.
Weight Weight Of Packages

UN NO : 3077
PROPER SHIPPING NAME :
CHEMICAL NAME : fluxametamide(NC-515)
CLASS : 09
PACKING GROUP : III
EMS : 11400
9000 KGS. 20 PALLTES
MARINE POLLUTANT : NA KGS.
Limited Q'ty :
FLASH POINT : NA
IIP CODE : 1G/Z 35/S/21/IND/01201987
INNER PACKAGES : 360 x 25 kg Fiber UN Approved drums - Palletized
OUTER PACKAGES : TOTAL 360 DRUMS
Total Pallets – 20 (18 drums on each pallet)
15 Container 16 Seal number(s) 17 Container size 18 Tare 19 Total gross
identification no. & type mass (kg) (incl. tare) (kg)
CONTAINER PACKING CERTIFICATE 21 RECEIVING ORGANIZATION RECEIPT
I hereby declare that the goods described above have Received the above number of packages/containers/trailers in
been placed/loaded into the container/vehicle identified apparent good order and condition, unless stated hereon:
above in accordance with the applicable provisions. RECEIVING ORGANIZATION RE-MARKS:
**MUST BE COMPLETED AND SIGNED FOR ALL
CONTAINER/VEHICLE LOADS BY PERSON
RESPONSIBLE FOR PACKING/LOADING
20 Name of company : Haulier's name 22 Name of company

Name/status of declarant : Vehicle reg no. Name/status of declarant :

Place and date : Signature and date Place and date :

Signature of declarant DRIVER'S


SIGNATURE Signature of declarant

* DANGEROUS GOODS
You must specify proper shipping name, hazard class, UN No., Packaging group, (where assigned) Marine pollutant and observe the mandatory
requirements, under applicable national and international governmental regulations.

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