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HazMat/ Dangerous Goods Declaration Form

Please follow the instructions below for all hazmat loads:

Fill out the form
Submit the form to Great White Fleet
Print off the submission confirmation page
Sign and Fax the confirmation page to 877-288-2683
Complete the (Container/Vehicle) Packing Certificate

All steps must be followed in order for your container to be spotted.

Vessel:
Voyage:
# of Packages:
Package Type:
Weight/Quantity:
RQ:	Yes No
Proper Shipping Name:
Technical Name:
Hazard Class:
UN Number:
Packaging Group:
Marine Pollutant:	Yes No
Flash Point:
Subsidiary Risk:
Poison Inhalation Hazard:	Yes No
24/hr Emergency Phone & Company:
EMS Number:
MFAG Number:
Booking #:
Container #:
Shipper:
Consignee:
Load Port:
Discharge Port:
Final Destination:

Shipper's Certification Statement: I hereby declare that the contents of the consignment are fully and accurately described above by the correct technical name, proper shipping name, and are classified, packaged, marked, and labeled/placarded, and are in all respects in proper condition for transport according to the applicable international and national government regulations.

It is declared that the packing of the container has been carried out in accordance with the General Introduction, IMDG Code, paragraph 12.3.7 or 17.7.7.

By submitting this form I am verifying that I have read the above statements and all above information is correct.

Your Email Address:

� 2005 Great White Fleet

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