Radioactive Material Transport Declaration Form
1. Shipper Information
Name
Organization
Address
Contact Number
2. Consignee Information
Name
Organization
Address
Contact Number
3. Material Details
Isotope/Radioactive Material
Activity (Bq, Ci)
Physical Form
Quantity
Package Type
Number of Packages
4. Transport Information
Mode of Transport
Road
Air
Sea
Rail
Transport Date
Vehicle/Receptacle No.
5. Declaration
Shipper's Signature
Date