MULTIMODAL DANGEROUS GOODS FORM

Shipper / Consignor / Sender Transport document number Shipper's referenceEmergency contact telephone : Freight forwarder's reference

(with international access code)Consignee Carrier (to be completed by the carrier)

Additional handling information:

Vessel name and voyage

Place of receipt Port of Loading

Port of Discharge Destination

Gross Mass (kg) Net Mass (kg) Cube (m3)

Seal No. Tare Mass (kg) Total gross incl. Tare (kg)

OOCL Contact : Tel nr: Fax nr:

For OOCL internal use only -

QF012 HQD 9/05

No. and kind of packages; description of goods (UN No., PSN, Class, PG)

Name of DeclarantDate and PlaceSignature of Declarant

Name of company

Name of DeclarantDate and PlaceSignature of Declarant

Name of Company

(SOLAS 74, Chapter VII, regulation 4 and MARPOL 73/78, Annex III, regulation 4.)

Container Packing Certificate. I herebydeclare that the goods described above have beenpacked/loaded into the container/vehicle identifiedabove in accordance with the applicable provisions.

MUST BE COMPLETED AND SIGNED FOR ALL CONTAINER LOADS(other than tanks) BY THE PERSON RESPONSIBLE FORPACKING/LOADING PER 5.4.2.1.

IMPORTANT NOTE: You must specify UN number, proper shipping name, class or division and packing group (where assigned) marine pollutant and observe the mandatory requirementsunder applicable national and international governmental regulations.

Shipper's declaration. I hereby declare that the contents of this consignmentare fully and accurately described above by the proper shipping name, and areclassified, packaged, marked and labelled/placarded and are in all respects in propercondition for transport according to the applicable international and nationalgovernmental regulations.

MUST BE COMPLETED AND SIGNED FOR ALL DANGEROUS GOODS CONSIGNMENTS BY THE PERSONRESPONSIBLE FOR OFFERING THE DANGEROUS GOODS FOR TRANSPORT PER 5.4.1.6

(Use and attach separate sheet to continue above if more entry)Container/Vehicle No. Container Size/Type

We, the undersigned company, hereby warrant and guarantee that the information provided hereunder is true, accurate, correct and complete,failing which may lead to your rejecting the container for shipment. We understand that the information may be used for preparing bill of ladingand submission or declaration to Customs and other relevant authorities. OOCL’s reliance on the information is hereby acknowledged. Weunderstand and agree that failure to provide true, accurate and complete information may result in delay, other damages and/or fines, and thatany such damages and/or fines shall be our sole responsibility and liability. We shall indemnify OOCL and hold OOCL harmless in respect ofany liability, loss, damage or expense which you may sustain as a result of any mis-declaration or false, inaccurate, incorrect or incompletedeclaration.

Shipping Marks

To: OOCL

Placards/Signs: