Trade and Industry Department
	Government of the Hong Kong Special Administrative Region
	Chemical Weapons (Convention) Ordinance (Cap. 578)		
Annual Report on Schedule 1 ChemicalS –
transfer/ ImPORT/ EXPORT OF EACH CHEMICAL During the Previous Year (FORM S1-2)	
Part A : Details of the facility (Note 1) and the chemical (Please use a new Form S1-2 for each chemical)	
1.	Facility name :
     	3.	IUPAC chemical name (Note 3) :
     	
2.	Permit number :
     	4.	CAS registry no.(Note 4) :      	
	5.	Year of past activities reported in this form
(i.e. the “reporting year”, must be a calendar year) :      	
Part B :	Details on each TRANSFER (Note 5) of the Schedule 1 chemical named in Part A FROM/TO (Note 10) other facilities located in Hong Kong or the Mainland China during the reporting year (Please use additional Form S1-2 if necessary)	
Item 1	(1)	The facility in this item  supplied chemicals to  received chemicals from (please mark ‘X’ in one of the boxes) the facility declared in Part A .	
	(2)	Details of the facility	
		Name	:	     		 Permit No.  BR No.	:	     		
					(Please mark ‘X’ to show the type of no. provided.
If the facility is not a permit holder, please provide BR No.)	
		Address	:	     		
	(3)	Details of the transfer
:	
		Quantity	:	     	grams	
		Purpose(s)	:		Research		Production of other Schedule 1 chemicals	
		(Please mark ‘X’ if applicable)			Medical		Waste disposal	
				Pharmaceutical		Protective uses	
				Other (please specify) :	     		
							
Item 2	(1)	The facility in this item  supplied chemicals to  received chemicals from (please mark ‘X’ in one of the boxes) the facility declared in Part A .	
	(2)	Details of the facility	
		Name	:	     		 Permit No.  BR No.	:	     		
					(Please mark ‘X’ to show the type of no. provided.
If the facility is not a permit holder, please provide BR No.)	
		Address	:	     		
	(3)	Details of the transfer
:	
		Quantity	:	     	grams	
		Purpose(s)	:		Research		Production of other Schedule 1 chemicals	
		(Please mark ‘X’ if applicable)			Medical		Waste disposal	
				Pharmaceutical		Protective uses	
				Other (please specify) :	     		
							
Part C :	Details of each IMPORT/EXPORT (Note 5) of the Schedule 1 chemical named in Part A FROM/TO other State Parties (Note 15) (other than the Mainland China) during the reporting year (Please use additional Form S1-2 if necessary)	
1.	The chemical in Part A is (please mark ‘X’ in one of the following) : 
 Exported to other State Parties  Imported from other State Parties
Please provide details relevant to the export/import -
Country of destination for export / origin for import
(other than Mainland China) :      	

Export/Import licence no. :      	

Date of export/import (dd/mm/yy) :      	

Quantity (in grams) :      		2.	Name and address of recipient for export / supplier for import :
	     	
	3.	Purpose(s) for the export / import (please mark ‘X’ if applicable) : 
	 Research	 Waste disposal
	 Medical	 Protective uses
	 Pharmaceutical	 Production of other Schedule 1 chemicals
	 Other (please specify) :      	

		
Part D : Total number of Form S1-2 submitted (including this page) :        	 pages
(Please submit this form together with Form S1-1. Also see Guideline 10)	
Part E : 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 :