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Dangerous Goods Shipment Request Form

Please complete the form and print a copy for your records, then click "Submit". If you have the MSDS, please fax to 683-6025.

1. Shipper Information

Name:

Requested Ship Date:

Department:

Phone:

Address:

E-mail:

Preferred courier (check one):

FedEx Airborne

UPS

Other

Account Number:

2. Destination Information

Name:

Company:

Department:

Phone:

Address:

3. Description of Items Being Shipped:

Material to be Shipped:

Technical name:

Manufacturer:

Product Number:

Physical State:

Liquid

Solid

Multi-phase (describe)

Gas

Other (describe):

Radioactive?

Yes

No

If Yes, Isotptope:

Activity:

Biological?

Yes

No

If yes, does it contain a Risk Group 2, 3, or 4 pathogen?

Yes

No

Pathogen Name:

Amount of material per container: (mg, kg, mL, L)

Container size:

# of containers:

Container Type:

Glass

Plastic Bag

Plastic

Metal Can

Ampoule

4. Special Shipping Requirements:

Cold Packs

Yes

No

Dry Ice Required?

Yes

No

Amount of dry ice required: (Kg)

5. Certification

I certify that all the information provided on this form is true and accurate.

Signature

Date:

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