(as recommended by International Maritime Organization)

Shipper (Name and Address)

Reference Number(s)


Name of Carrier (or Carrier's Agent)

Name/Means of Transport

Port/Place of Departure

Port/Place of Destination


Marks and Numbers; Numbers and Kinds of Packages: Description of Goods* Indicate: Hazard Class/Division; Packaging Group (When Required),UN Number, Flashpoint ( When Required, in C); Marine Pollutant (When Required)

*Proper Shipping Name: Propriety names alone are not sufficient.
Gross Mass (Kg)
Net Quantity (When Required)





Additional Information:

" I hereby declare that the contents of this consignment are fully and accurately described above by the correct technical name(s) (proper shipping name(s)), and are classified, packaged, marked and labelied , and are in all respects in proper condition for transport by(insert mode(s) of transport involved) according to the applicable international and national government regulations"

Name/Status of Signatory ____________________

Place and Date_____________________________

Signature on Behalf of Shipper_________________