Fillable CHECK HERE IF YOU CERTIFY THAT THIS ITEM (Washington State University at Vancouver)

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CHECK HERE IF YOU CERTIFY THAT THIS ITEM (Washington State University at Vancouver)

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  • 11 check-boxes
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Country of origin: US
File type: PDF

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Shipping Date:____/_____/_____
Recipient (Please Print) _________________________________________________
Recipient Address: _____________________________________________________
CHECK HERE IF YOU CERTIFY THAT THIS ITEM IS NOT HAZARDOUS
NOTE: LOOSE ICE IS FORBIDDEN (
& 
) – PLACE IN LEAK PROOF CONTAINER
Department: _________________________ Telephone (____) ______ - ________
Principle Investigator (please PRINT): ________________________________________
Name of Shipper (please PRINT): ________________________________________
Certifying Signature: _____________________________________________________
WSU Employee or Student ID Number: ______________________________
Item Description (attach a detailed description if it will not fit here)
_____________________________________________________________________________
_____________________________________________________________________________
This item IS HAZARDOUS for the following reason(s) (Circle as appropriate)
Note: The SHIPPER is responsible for the correct packaging and all required labeling. This
form is NOT to be considered “In lieu of” correct packaging and labeling. Call the WSU
Vancouver Mail Room (6-9708) for packaging supplies or EH&S (6-9706) for assistance in
identifying the requirements for shipment.
1. Explosives
2. Gases (Inhalation Hazard, Non-Flammable Gas, Flammable Gas, Oxygen)
3. Flammable Liquid(s)
4. Flammable Solid, Spontaneously Combustible, Dangerous When Wet
5. Oxidizer and Organic Peroxides
6. Poison (Toxic)
7. Radioactive
8. Corrosive
9. Miscellaneous (Such as Dry Ice)
For Mailroom Use Only Below This Line:
Package Tracking Number: _________________________________________
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CHECK HERE IF YOU CERTIFY THAT THIS ITEM (Washington State University at Vancouver)

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Completed 2 February 2021

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