Dept:



|Dept Name: |INTERNATIONAL |Date: |

|GEOLOGY DEPT. 3006 |SHIPPING REQUEST |      |

| |

|Pick One: |

|Pick One: |

|Duties & Fees Charged to: | |Sender | |Receiver | | |

| |

|HazMat: | |Dry Ice – lbs:       | |Class:       (must have papers attached) |

| |

|Description of contents: (required) |If you are (1) shipping items outside the US to conduct research or (2) sending |

| |specimens outside the US, have you contacted the Compliance Attorney to discuss export? |

| | |

| |     Yes      No      NA |

|Value for Insurance & Custom Purposes (NTE 50K): |E-mail tracking number to: |

|(automatically insured to $100.00) $      |      |

|Address: 35 characters only per line including spaces (print please) Collect Shipping Number |

|Company |      |________________ |

|Attention |      | |

|Address 1 |      | |

|Address 2 |      | |

| | | |

| | | |

| | | |

| | |Shipper’s signature below certifies, under penalties of up |

| | |to $55,000 per violation prescribed by 49CFR 107.329, |

| | |that there are no DOT-regulated materials in the package |

| | |unless indicated above. |

|City |      | |

|State |      |Country |      | |

|Postal Code |      |Telephone |      | |

| | |Required – | | |

| | |Receivers # only | | |

| |

|Signature: |Printed Name:      |

|Phone:      | |

PLEASE FILL IN COMPLETELY OR PACKAGE CANNOT BE PICKED UP OR SHIPPED

Old forms will not be accepted after July 1, 2014

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download