Trade and Industry Department
Government of the Hong Kong Special Administrative Region
Chemical Weapons (Convention) Ordinance (Cap. 578)		
ANNUAL REPORT ON SCHEDULE 1 CHEMICALS –
PAST ACTIVITIES AT THE FACILITY DURING THE PREVIOUS YEAR (FORM S1-1)	
Part A : Details of the facility (Note 1) 	
1.	Facility name :      	3.	Permit number :      	
2.	Name of the owner, company or enterprise operating the above facility :
     	4.	Year of past activities reported in this form 
(i.e. the "reporting year", must be a calendar year) :      	
(Please mark ‘X’ in one of the following and provide details) :
HKID no. Passport no. BR no.:        	
other relevant registration no. (please specify) :      	5.	Facility address :	      	
	Tel no:      	Fax no.:      	
Part B :	Details of each Schedule 1 chemical produced, stored, consumed by and/or transferred from the facility 
(Please use a new Form S1-1 for each chemical)	
1.	IUPAC chemical name (Note 3) :      	3.	Structural formula :
     	
2.	CAS registry no.(Note 4) :      		
4.	Production (Note 5) of the chemical in the reporting year :
	Yes		No	(please mark ‘X’)	
	If yes, please indicate the quantity produced :        	 grams
Purpose(s) of production (please ‘X’ if applicable) :	
 Research	 Medical	 Pharmaceutical   Protective
 Waste disposal   Production for other Schedule 1 chemicals
 Others (please specify) :      	7.	Maximum quantity of the chemical stored at any time during the reporting year :        	 grams
	Quantity of the above chemical stored at the end of the reporting year :
	       	 grams	
	8.	Purpose(s) of storage (please mark ‘X’ if applicable) :	
 Research	 Medical	 Pharmaceutical   Protective
 Waste disposal   Production for other Schedule 1 chemicals
 Others (please specify) :      	
5.	Precursor chemicals listed in Schedules 1, 2 and 3 to the Chemical Weapons Convention used in producing the above Schedule 1 chemical :
	Yes		No	(please mark ‘X’)
If yes, please indicate – 
Precursor IUPAC chemical name :	       	
CAS registry no. :         	
Quantity used (in grams) :         		9.	Transfer to/from (Note 5) other facilities located in either Hong Kong or Mainland China during the reporting year :
	Yes		No	(please mark ‘X’)

If yes, please indicate the quantity below and submit Form S1-2 for details of the transfer :
(a)	Transferred from	:        	 grams
(b)	Transferred to	:        	 grams		
6.	Consumption (Note 5) of the chemical in the reporting year :
	Yes		No	(please mark ‘X’)	
If yes, please indicate the quantity consumed :        	 grams
Purpose(s) of consumption (please mark ‘X’ if applicable) :	
 Research	 Medical	 Pharmaceutical	 Protective
 Waste disposal    Production for other Schedule 1 chemicals
 Others (please specify) :      	10.	Import from/export to (Note 5) other State Parties (except Mainland China) of the Chemical Weapons Convention (Note 15) during the reporting year :
	Yes		No	(please mark ‘X’)
If yes, please indicate the quantity below and submit Form S1-2 for details of the import/export:
(a)	Imported	:        	 grams
(b)	Exported	:        	 grams
	
11. Change at the facility or its relevant part(s) during the reporting year compared to previously submitted technical description of the facility (i.e. Form S1) :
 Yes	 No (please mark ‘X’)  If yes, please submit Form S1 to provide updated information.	
Part C : Supporting documents (Guideline 8 and 10)	
Please mark ‘X’ if the following forms are submitted with this report and provide the total number of pages submitted:	
	Form S1-1 (including this page)	:	       		pages	
	Form S1-2 (for Part B.9 and B.10)	:	       		pages	
	Form S1 (for Part B.11)	:	       		pages	
Part D : Undertaking by the permit holder	
I, the undersigned, hereby declare to the best of my knowledge and belief, that all information provided in this form and in any additional pages attached to this form is true and correct.  I also declare that, in submitting this form, I fully understand that Trade and Industry Department reserves at all times the right to release the above information and any information relates to this report, including particulars of the undersigned, to third parties for purposes stated in Section 28(2) of the Chemical Weapons (Convention) Ordinance (Cap. 578).
Name of the permit holder of the facility :      
Signature of the permit holder and company chop :

Date :      	For official use only
Date of receipt : 

Remarks :