****** DANGEROUS GOODS SHIPPING DOCUMENT ******
CONSIGNOR (shipper):
Name:
Address:


INTERNAL DOCUMENT LABEL:

MODE OF TRANSPORTATION
ROAD ____ RAIL ____ SHIP ____
CONSIGNEE:
Address:


ADD FOR SHIP ONLY:

Initial Carrier:
Name:
Licence Plate # :
DANGEROUS GOODS
UN
Number
Proper Shipping Name Primary
Class
Sub
Class
Packing
Group
Toxic by
Inhalation
(SP 23)
Total
Weight/Vol
Number of
Packages
































NONDANGEROUS GOODS












PLACARDS REQUIRED:
Quantity: ____________
Type: ________________
EXEMPTION PERMIT:
NUMBERS: ____________
LETTERS: ________________
Drivers Signature:
X___________________________________
PO/Sales Order #: ___________________
For help in chemical emergencies involving spill, leak or damaged packaging:


NAME:
TITLE:
PLACE:
DATE:
Phone Number: _____________________________

Signature: ________________________________
I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, are properly classified and packaged, have dangerous goods safety marks properly affixed or displayed on them, and are in all respects in proper condition for transport according to the Transportation of Dangerous Goods Regulation.

Shipper's Name(please print): ________________________________