Explosive Materials Domestic Shipping Declaration

Shipper Name

Shipper Address

Recipient Name

Recipient Address

Contact Number

Description of Explosive Material(s)

Quantity

UN Number

Class/Division

Net Explosive Mass (kg)

Packaging Description Emergency Contact

Additional Information / Handling Instructions

Declaration: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packed, marked, and labeled/placarded, and are in all respects in proper condition for transport according to applicable regulations.

Authorized Signature

Date