<p> MULTIMODAL DANGEROUS GOODS FORM MO41/A This form meets the requirements of SOLAS 74, Chapter VII, regulation 5 and MARPOL 73/78, Annex III regulation 4. NOTE: When this form is used as container/ vehicle packing certificate only, not a combined document, a dangerous goods declaration signed by the shipper or supplier must have been issued/received to cover each dangerous goods consignment packed in the container. The container/vehicle packing certificate is not required for tanks.</p><p>1Shipper/Consignee/Sender 2 Transport document number</p><p>3 Page of 3 Shipper’s reference pages 24 HOUR contact Number: (1800 numbers 5 Freight forwarder’s should not be used) reference</p><p>6 Consignee 7 Carrier (to be completed by the carrier) </p><p>SHIPPERS DECLARATION (refer 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 Passenger and Cargo Aircraft/ Cargo Aircraft Only (delete non-applicable) 10 Vessel/flight No. and 11Port/place of date loading </p><p>12 Port/place of 13 Destination discharge</p><p>14 Shipping Gross Mass Net Mass Cube No. and kind of packages; description of goods* marks (kg) (kg) (m3)</p><p>15 Container 16 Seal 17 Container/Vehicle 18 Tare Mass 19 Total Gross identification No./ number(s) size & type (kg) (including tare) (kg) vehicle registration No.</p><p>CONTAINER/ VEHICLE PACKING CERTIFICATE 21 RECEIVING ORGANIZATIONRECEIPT I hereby declare that the goods described above have been Received the above number of packages/containers/trailers in apparent good order packed/loaded into the container/vehicle identified above in and condition unless stated hereon. accordance with the applicable provisions+ Receiving organization remarks: Must be completed and signed for all container/vehicle loads by person responsible for packing/loading. 20 Name of company (see note 2 on Haulier’s name 22 Name of company reverse)</p><p>Name/Status of declarant Vehicle reg. No. Name/Status of declarant</p><p>Place and date Signature and date Place and date</p><p>Signature of declarant DRIVER’S SIGNATURE Signature of declarant MULTIMODAL DANGEROUS GOODS FORM MO41/A This form meets the requirements of SOLAS 74, Chapter VII, regulation 5 and MARPOL 73/78, Annex III regulation 4. NOTE: When this form is used as container/ vehicle packing certificate only, not a combined document, a dangerous goods declaration signed by the shipper or supplier must have been issued/received to cover each dangerous goods consignment packed in the container. The container/vehicle packing certificate is not required for tanks.</p><p>DANGEROUS GOODS: You must specify – proper shipping name, hazardous class, UN No., packing group (where assigned) marine pollutant and observe the mandatory requirements under the applicable national and international governmental regulations. For the purposes of the IMDG Code see 5.4.1.1. (see note on reverse). + For the purpose of the IMDG Code, see 5.4.2 (see note on reverse) AMSA 250 (01.02)</p>