TRANSPORT ORDER

Transport order

SHIPPER:

Name Institution sender*

Email address*

Contactperson*

Title*

Mr.

Mrs.

Department

Room/ Location

Address*

Zip Code*

City

Country*

Telephone number*

Account or order reference*

CONSIGNEE:

Name Institution receiver*

Contactperson*

Title*

Mr.

Mrs.

Department

Address*

Zip Code*

City*

Country*

Telephone number*

E-mail address*

Pick-up date*

Pick-up time from

Express shipment (same day shipment at extra costs)?

yes

Is it known or reasonably expected that the goods are infectious?*

yes

If yes, what is the risk group (WHO) of the material?

Are the goods genetically modified?*

yes

If yes, what is the licence level or group of the material?

ML I / II

ML III / IV

Description of goods (in case of infectious, description of the virus and if possible carrier)*

Are the good subject to export authorisations (EU 428/2009)?

yes

If yes, what is the authorization number?

Package

Number

Dimensions*

Quantity per vial / jar (gram/ml)*

Package

Number

Dimensions

Quantity per vial / jar (gram/ml)

Package

Number

Dimensions

Quantity per vial / jar (gram/ml)

Total quantity of shipment (gram/ml)*

Is the reason of sending for diagnostic purposes?

yes

Do you want to have an additional transport insurance (value > € 87 per kg.)?

yes

If yes, what is the value of the shipment?

Are cooling packs to be used for this shipment?

yes

Are cooling packs to be provided by B.L.S.?

yes

Is Dry Ice to be used for this shipment?

yes

Is Dry Ice to be provided by B.L.S.?

yes

If not, package contains (kg)

Do you have packages which are in accordance with ADR/IATA?

yes

Are packages to be provided by B.L.S.?*

yes

Is a datalogger to be provided by B.L.S. (at extra costs)?

yes

For this order the General conditions of SGS Nederland B.V. are applicable, unless otherwise agreed upon, and additionally for transport the following conditions shall apply: for national transport the AVC conditions, for international road transport the CMR conditions and for air transport the Montreal convention.

Do you agree with the General conditions?*

yes

Extra comments

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