1)船名/航次(VSL/VOY)：____________
2)訂艙號(Booking No.)：_______________
3)箱 量/型(Equipment volume/type):__________________
4)起運港(POL)：___________________________________
5)中轉港（POD）:
6)目的 港(Final destination) : ________
7)中文品名(Commodity description in Chinese)：
英文品名(Commodity description in English)：
產品包裝(Package)：___PALLETS___________________________________
件數(Volume )：________PALLETS_________________________
產品重量(Weight)：_____0KGS____________________________
產品外觀與性狀(Commodity shape and property)： _____________
本產品主要用途(Utility of Goods )____ __________
我司特此證明上述產品為一般化工品，不屬於《國際海運危險貨物規則》一書中所列的危險品。其包裝及裝載均符合海上運輸要求。如以上陳述不實而引起在運輸途中發生任何問題，承運人有權按照《中華人民共和國海商法》第六十八條規定在任何時間、任何地點根據情況需要將貨物卸下、銷燬或者使之不能為害，而不負賠償責任。我司對承運人因運輸此類貨物所受到的損害，應當負賠償責任。而且承運人將保留依照有關法律及港監有關規定向我司追究法律責任的權利。所有責任與相關費用由我司承擔！
We hereby confirm above goods belongs to common chemical product which is not in the dangerous
cargo list of <
in conformity with the regulations governing the maritime transportation of such goods.
In case of any an actual danger to the ship, the crew and other persons on board or to other goods as
a consequence of failure to declare above inaccurately, according to Article 68 of << MARITIME CODE OF THE PEOPLE’S REPULIC OF CHINA>>, the carrier may have such goods landed, destroyed or rendered innocuous when and where circumstances so require, without compensation. The undersigned shall be liable to the carrier for any loss, damage or expense resulting from such shipment. Carrier will also hold the right for any legal action against relative laws or regulations. The undersigned will be liable for all the responsibility and cost that may cause.
貨代蓋公章/Booking agent) (發貨人蓋公章/Shipper)