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
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