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Page 1: Dangerous Goods Declaration - K"LINE · Dangerous Goods Declaration Shipper/Consignor/Sender of Record Transport document number - _____ pages. Page _____ of Shipper’s reference

Dangerous Goods Declaration

Shipper/Consignor/Sender of Record

Transport document number -

Page _____ of

_______ pages.

Shipper’s reference

Booking No.

Freight Forwarder's reference

Consignee

Carrier (to be completed by carrier)

Vessel Name and voyage Emergency contact telephone (with international access code)

Additional handling information: Place of receipt Port/place of loading

Port/place of discharge

Destination

Placards/Signs:

Shipping marks

No. and kind description of goods Gross mass (kg) Net Explosive Qty. of packages (class 1 only)

15. Container identification no./ vehicle registration no.

16.

17. Seal number(s)

18. Container/vehicle size & type

19. Tare mass (kg)

20. Total gross including tare (kg)

CONTAINER/VEHICLE PACKING CERTIFICATE It is declared that the packing of the goods into the container/vehicle identified above has been carried out in accordance with the applicable provisions. MUST BE COMPLETED AND SIGNED FOR ALL CONTAINER/VEHICLE LOADS (other than tanks) BY THE PERSON RESPONSIBLE FOR PACKING/LOADING.

SHIPPER’S DECLARATION I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded and are in all respects in proper condition for transport according to the applicable international and national governmental regulations. MUST BE COMPLETED AND SIGNED FOR ALL DANGEROUS GOODS CONSIGNMENTS BY THE PERSON RESPONSIBLE FOR OFFERING THE DANGEROUS GOODS FOR TRANSPORT PER IMDG CODE 5.4.1.1.11.

Name of company packing container J.

22. Name of company of shipper 23.

Name/status of declarant

Name/status of delcarant

Place container/vehicle packed Date packed:

Place and date

Signature of declarant

Signature of declarant

Form Instructions
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Instructions
This form can be filled out on screen and then printed or printed then filled out. Be sure all information entered in a field, fits in that field. If not, edit the text to fit. When printing ensure that Annotations (under Print Range) and Fit to Page (under Properties) are NOT checked.

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