Shipper S Name & Address(託運人名稱 地址)
Total Page：16
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IMO DANGEROUS GOODS DECLARATION This form meets the requirements of SOLAS’74 chapter VII, regulation 5:
MARPOL 73/78 Annex III, regulation 4 and the IMDG Code, General Introduction, section 9
Shipper Reference number(s)
s/o
booking no:
Consignee Carrier
Container packing certificate/vehicle declaration Name/status, company/organization of signatory
DECLARATION Place and date
It is declared that the packing of the container/vehicle has been carried out in Signature on behalf of packer accordance with the General Introduction. IMDG Code. Paragraph 12.3.7 or 17.7.7.
TO BE COMPLETED FOR SHIPMENTS IN CONTAINERS OR VEHICLES
Ship’s name and voyage No. Port of loading (Reserved for text, instructions or other matter)
Port of discharge
Marks & No. Number and kind of packages, proper shipping name*, IMO hazard Gross mass (kg), net Good delivered as
If applicable. Identification or class/division, UN Number, packaging group (where assigned)**, flashpoing quantity/mass** registration number(s) of the unit (in C c.c.)**, control and emergency temperatures**, identification of the □ Breakbulk cargo
goods as MARINE POLLUTANT**, EMS No. and MFAG table No.***
□ Unitized cargo
□ Bulk packages
Type of unit (container, trailer,
tank vehicle, etc.)
Container number: □ Open
□ Closed
Insert “X” in appropriate box
(This column may be left
empty apart from the heading,
in which case insert
appropriate description) ‘Synonyms should not be used. Proprietary/trade names alone are not sufficient. If applicable: (1) the word “WASTE” should precede the name: (2) “EMPTY
UNCLEANED” OR “RESIDUE – LAST CONTAINED” should be added; (3) “LIMITED QUANTITY” should be added.
** When required in 9.3 of the General Introduction to the IMDG Code.
*** When required
ADDITIONAL INFORMATION
In certain circumstances special information/certificates are required. See IMDG Code, General Introduction, paragraphs 9.7.1, 9.7.2, 9.9.1 and 9.10.1.
DECLARATION Name/status, company/organization of signatory
I hereby declare that the comtents of this consignment are fully and accurately described above by the proper shipping Place and date name(s), and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and Signature on behalf of shipper national governmental regulations.
IMDG CODE – PAGE 0039 Amdt. 27-94
CONTAINER PACKING CERTIFICATE Booking no: vessel&voyage:
Those responsible for the packing of dangerous goods into a container shall certify that this has been properly carried out and embodying the following provisions :
1) The container was clean, dry and apparently fit to receive goods.
2) No incompatible substances have been packed into the container.
3) All packages have been externally inspected for damage, and only sound packages packed.
4) All packages have been properly packed in the container and safely secured.
5) The container and packages are properly marked and labelled.
6) All packages packed according to IMCO.
7) 24 HOURS EMERGENCY CONTACT: Port of Loading: Port of discharge: Container number Contents of Packing Tons U. N. Packing IMCO Container Number group Class
We hereby certify that the abovementioned requirements are fulfilled.
Received onboard: Date:
Chief Officer Signature