Signature on behalf of shipper Name/status, company/organization of signatory Place and Date Shipper Consignee This form meets the requirement of SOLAS 74 chapter VII
Note: The provisions of 2.3 and Table 2.3.A may be limited by State or operator variations. Passengers should check with their airline for the current provisions
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SHIPPER'S DECLARATION FOR DANGEROUS GOODS
(Provide at least three copies to the airline.)
Shipper
Air Waybill No. Page
of
Pages
Shipper's Reference Number (optional)
Consignee
This shipper's declaration was prepared using a FedEx Express template. It must be used ONLY for: * Class 7 radioactive shipments * Shipments using an 023 air waybill (IP1, IXF or ATA service) * Shipments originating from a non-US location
Two completed and signed copies of this Declaration must be handed to the operator
WARNING
TRANSPORT DETAILS
Failure to comply with all respects with the applicable Dangerous Goods Regulations may be in breach of the applicable law, subject to legal penalties.
This shipment is within the limitations prescribed for: (delete non applicable) PASSENGER AND CARGO AIRCRAFT
Airport of Departure
CARGO AIRCRAFT ONLY
Shipment type: (delete non-applicable)
Airport of Destination:
NON-RADIOACTIVE
RADIOACTIVE
NATURE AND QUANTITY OF DANGEROUS GOODS
Dangerous Goods Identification UN or ID No.
Proper Shipping Name
Class or Division (Subsidiary Risk)
Packing Group
Quantity and type of packaging
Packing Inst.
Authorization
Additional Handling Information
I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labelled/placarded, and are in all respects in proper condition for transport according to applicable International and National Governmental Regulations. I declare that all of the applicable air transport requirements have been met.
Name/Title of Signatory Place and Date Signature
(see warning above)
Emergency Telephone Number
FOR RADIOACTIVE MATERIAL SHIPMENT ACCEPTABLE FOR PASSENGER AIRCRAFT, THE SHIPMENT CONTAINS RADIOACTIVE MATERIAL INTENDED FOR USE IN OR INCIDENT TO RESEARCH, MEDICAL DIAGNOSIS, OR TREATMENT. ADR EUROPEAN TRANSPORT STATEMENT: CARRIAGE IN ACCORDANCE WITH 1.1.4.2.1
