Dangerous Goods Declaration Form for Vessels

1. Shipper and Consignee

Shipper Name & Address

Consignee Name & Address

Shipping Reference No.

Date

2. Transport Details

Vessel Name

Voyage No.

Port of Loading

Port of Discharge

3. Dangerous Goods Description

Description of goods	Class or Division	UN No.	Packing Group	Quantity & Type of Packing	Flashpoint (°C)	Marine Pollutant

4. Additional Information

Additional Handling Information

5. Certification

Declarant's Name

Signature

Date

Company Stamp