Multimodal DG Form

IMDG DANGEROUS GOODS DECLARATION

This form meets the requirements of SOLAS 74, chapter VII, regulation 5

1. Shipper / Consignor

2. Transport Document 4. Shipper’s Reference 5. Freight forwarder’s ref.

3. Page of Pages

2. Consignee / Receiver

8. Limitations 9. Additional handling information:

7. Carrier

10.VslVoy

11. POL

12. POD

13. Dest.

14. Shipping Marks

Description of Hazardous Goods*

Gross Mass(kg)

Volume Cube(m³)

15. Container No	ISO Code	16. Seal Number	17. Size & Type	18. Tare Mass (kg)	19. Total Gross Mass (kg)
No container data found

15. Container No

ISO Code

16. Seal Number

17. Size & Type

18. Tare Mass (kg)

19. Total Gross Mass (kg)

No container data found

20. CONTAINER/VEHICLE PACKING CERTIFICATE

Company Name

Declarant Name

Date of Signing

Place and Signature

21. Receiving Organisation 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 Name

Date of Signing

Place and Signature

22. Shipper

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

Shipper’s Name

Company Name

Date of Signing

Place and Signature