![[Company Logo Image]](Polonez_Logo/Polonez1.gif){kind=logo}
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143 Doty Cir.
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SHIPPER'S ENDORSEMENT |
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"I hereby certify that this shipment does not contain any unauthorized explosives, incendiaries or hazardous materials. I consent to a search of this shipment. I am aware that this endorsement and original signature, along with other shipping documents, will be retained on file for at least thirty days." |
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| Original Shipper (signature) __________________________ | Date ____________ |
| Name (print) ____________________________________ | Title: Original Shipper |
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ORIGINAL SHIPPER SIGNATURE & INFORMATION |
Original Shipper (signature) ________________Name (print) ______________________ |
| Type of first personal identification
reviewed: ______________________________ |
| Matching photo on ID (mandatory)............[
] Yes |
| Number appearing on ID
______________________________________________ |
| Type of second personal identification
reviewed (if first is not government issued photo ID):______________________________________ |
| Matching photo on ID (indicate)
.................[ ] Yes .................. [ ] No |
| Number appearing on ID
______________________________________________ |
| Name of a person for whom shipment was accepted, if different from the shipper: ____________________________________________ |
| Agency Name
_________________________________________________ |
| Agent Signature
_______________________________________________ |
| Verified by Polonez Representative's
(signature) ______________________________ |
| HAWB Parcel #_______________________________________ CN#_________________________________ |