Hazmat Transport Request

Hazardous Materials Transportation Profile and Information Form

If expedited shipping overnight with dry ice, have package to the EHS building no later than 10am

91 Hickory Lane, University, MS 38677

From

Contact information of staff requesting material to be shipped who can be contacted with questions and coordinate pick up

Name

Department

Building

Room

Phone

UM email address / webid@olemiss.edu

Ship To

Name

Name of Contact to receive materials

Company

Company name receiving materials

Address 1

Address 2

City

State

Zip

Country

Company Phone

Phone

Material Details

Do not seal the outer packaging

Delivery Date

When do you need the package at the destination?

mm/dd/yyyy

Return Authorization #

If applicable

Special Instructions

Original Shipping Papers

Do you have the Original Shipping Papers?

Yes

FedEx Account Number

Do not enter your University Account number here, only FedEx shipper account number if available

Material

Name of Material (attach additional info sheet if necessary)

Material Info Sheet

Drop your files here

Amount

Chemical Components

List chemical components if material is a mixture

Send me a copy of my responses

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