Shipping Hazardous Chemicals Declaration

Shipper Information

Company Name Address Contact Person Phone Number Email

Consignee Information

Company/Name Address Contact Person Phone Number Email

Shipment Details

Shipment Reference/Number Date of Shipment Mode of Transport

Chemical Details

Chemical Name	UN Number	Class	Packing Group	Quantity	Packaging Type

Declaration

I hereby declare that the contents of this consignment are fully and accurately described and are properly classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national government regulations.

Name Position Signature Date