Multimodal DG Form

1. Shipper/Consignor/Sender		2. Transport Document Number	3. Page ___ of ___ pages
4. Shipper's Reference		5. Freight Forwarder's Reference
6. Consignee
7. Carrier (to be completed by the carrier) SHIPPER'S DECLARATION: I hereby declare that the contents of this consignment are fully and accurately described below by the proper shipping name(s), 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.
8. This shipment is within the limitations prescribed for:
9. Additional Handling Information	10. Vessel/Flight No.	11. Port/Place of Loading	12. Port/Place of Discharge
13. Destination
14. Shipping Marks	No. and Kind of Packages; Description of Goods*	Gross Mass (kg)	Cube (m³)
15. Container ID / Vehicle Reg. No.	16. Seal Number(s)	17. Size & Type	18. Tare Mass (kg)
19. Total Gross Mass (incl. tare)
20. CONTAINER/VEHICLE PACKING CERTIFICATE I hereby declare that the goods described above have been packed or loaded into the container/vehicle identified above in accordance with the applicable provisions. Name of person responsible for packing/loading
Name of Company	Name of Declarant	Place and Date	Signature of Declarant
21. RECEIVING ORGANIZATION RECEIPT Received the above number of packages/containers/trailers in apparent good order and condition unless stated hereon. Receiving Organization Remarks
Haulier’s Name	Company (or Shipper)	Place and Date	Driver’s Signature