SHIPPER’S DECLARATION FOR DANGEROUS GOODS

Shipper Air Waybill No:

CURIUM NETHERLANDS B.V. Page 1 of 1 pages
WESTERDUINWEG 3 Shipper’s references (optional):
1755 LE PETTEN
THE NETHERLANDS (TR 37042281) 399020

Consignee:
CENTRO DE CANCER EMMA ROMERO By order of:
CALLEJAS CENTRO DE CANCER EMMA ROMERO
CALLE ATENAS, IL ETAPA, CALLEJAS
COLONIA LOMAS DEL GUIJARRO CALLE ATENAS, IL ETAPA,
TEGUCIGALPA HONDURAS COLONIA LOMAS DEL GUIJARRO
TEGUCIGALPA HONDURAS

WARNING
Failure to comply in all respects with the applicable
Dangerous Goods Regulations may be in breach of
the applicable law, subject to legal penalties.
Two completed and signed copies of this Declaration must be handed to the operator.

TRANSPORT DETAILS
This shipment is within the limitations prescribed for: Airport of Departure:
(delete non-applicable)
AMSTERDAM
PASSENGER AND CARGO AIRCRAFT XXXXXXXXXXXXXXXXXX
CARGO AIRCRAFT ONLY
XXXXXXXXXXXXXXXXXX
Airport of Destination: TEGUCIGALPA Shipment type: (delete non applicable)
NON - RADIOACTIVE
XXXXXXXXXXXXXXXXXXXX RADIOACTIVE

NATURE AND QUANTITY OF DANGEROUS GOODS

UN Number or Identification Number, Proper shipping name, Class or Division (subsidiary hazard), Packing Group (if required), and all other required information.
UN3332, RADIOACTIVE MATERIAL, TYPE A PACKAGE, SPECIAL FORM , 7 // Ir-192, 1 type A package x 450.46 GBq //
II-Yellow, TI 0.8, dimensions 32x 32x 41cm
Special form certificate: D/0070/S-96 (Rev.7) attached

Additional Handling Information: RADIOACTIVE MATERIAL for human med. diagn/ Name/Title of Signatory:
treatment.Emergency contact/24-Hour Number +31-653826013(USA:011-31-653826013) R. Hoekstra
Ass. Traffic&Customs
I hereby declare that the contents of this consignment are fully and accurately described above by the proper Place and date: Petten, 12 Jun 2023
shipping name, and are classified, packaged, marked and labelled/placarded, and are in all respects in proper
condition for transport according to applicable international and national governmental regulations.
Signature:
I declare that all of the applicable air transport requirements have been met. (See warning above)