1. Shipper/Consignor/Sender 2. Transport document number 3. Page of pages 4. Shipper’s reference (page auto-numbers top right) 5. Freight forwarder’s reference 24 hour contact number: 6. Consignee 7. Carrier (to be completed by the carrier) SHIPPER'S DECLARATION (refer to box 22 below) 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 and date 11. Port of loading 12. Port of discharge 13. Destination 14. Shipping marks No. and kind of packages; description of goods* Mass (kg) Net Mass Cube (kg) (m3) 15. Container identification 16. Seal number(s) 17. Container/vehicle size & 18. Tare mass 19. Total gross No./ type (kg) (incl tare) (kg) Vehicle registration No. 21. RECEIVING ORGANIZATION RECEIPT Received the above number of packages/containers/trailers in apparent I hereby declare that the goods described above have good order and condition unless stated hereon. been packed/loaded into the container/vehicle identified Receiving organization remarks: above in accordance with the applicable provisions† Must be completed and signed for all container/ vehicle loads by person responsible for packing/loading. 20. Name of company (see note 2 on notes page) Haulier’s name 22. Name of company (of shipper preparing this note) 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
1. Shipper/Consignor/Sender 2. Transport document number 3. Page of pages (page auto-numbers top right) 4. Shipper’s reference 24 hour contact number: 5. Freight forwarder’s reference 6. Consignee 7. Carrier (to be completed by the carrier) SHIPPER'S DECLARATION (refer to box 22 below) 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 and date 11. Port of loading 12. Port of discharge 13. Destination 14. Shipping marks No. and kind of packages; description of goods* Mass (kg) Net Mass (kg) Cube (m3) 15. Container identification No./ Vehicle registration No. 16. Seal number(s) 17. Container/vehicle size & type 18. Tare mass (kg) 19. Total gross (incl tare) (kg) I hereby declare that the goods described above have been packed/loaded into the container/vehicle identified above in accordance with the applicable provisions† Must be completed and signed for all container/ vehicle loads by person responsible for packing/loading. 21. RECEIVING ORGANIZATION RECEIPT Received the above number of packages/containers/trailers in apparent good order and condition unless stated hereon. Receiving organization remarks: 20. Name of company (see note 2 on notes page) Haulier’s name 22. Name of company (of shipper preparing this note) 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
AMSA250-DG-form-2013.docx