Mercury Devices Transport Declaration
Shipper Name
Shipper Address
Consignee Name
Consignee Address
Device Description
Number of Devices
Total Quantity of Mercury (g)
Transport Date
Mode of Transport
I hereby declare that the above information is true and correct, and that the mercury-containing devices have been properly packaged and labeled according to applicable transport regulations.
Shipper Signature
Consignee Signature
Date
Date