IMSBC Declaration

Shipper's Name & Address

Consignee's Name & Address

Vessel Name

Port of Loading

Port of Discharge

Cargo Information

Description of Bulk Cargo	Bulk Cargo Shipping Name (BCSN)	Class (if applicable)	UN Number (if applicable)	IMSBC Group	Quantity	Stowage Factor	Angle of Repose	Moisture Content (%)	Transportable Moisture Limit (TML)	Chemical Properties	Special Handling / Precautions

Additional Information or Remarks

Statement:

I hereby declare that the cargo described above is correctly named, classified, packed, marked and labeled/placarded, and in proper condition for carriage by sea in compliance with the applicable provisions of the IMSBC Code.

Date

Shipper's Name

Signature and Stamp