Dept: - University of Wyoming
|Dept Name: |DOMESTIC |Date: |
|GEOLOGY DEPT. 3006 |SHIPPING REQUEST | |
| |
|Pick One: |
|Pick One: |
|Specials: | |Saturday Delivery | |Early A.M. | |Signature Req. |
| |
|HazMat: | |Dry Ice – lbs: | |Class: (must have papers attached) |
| |
|Value for Insurance Purposes (NTE 50K): |E-mail tracking number to: |
|(automatically insured to $100.00) $ | |
|Description of contents: |
|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 | | | | |
|Zip | |Telephone | | |
| |
|Signature: |Printed Name: |
|Phone: | |
PLEASE FILL IN COMPLETELY OR PACKAGE CANNOT BE PICKED UP OR SHIPPED
Old forms will not be accepted after June 1, 2011
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