Trade and Industry Department
		Government of the Hong Kong Special Administrative Region
	Chemical Weapons (Convention) Ordinance (Cap. 578)		
ANNUAL REPORT ON SCHEDULE 1 CHEMICALS –
ANTICIPATED ACTIVITIES AT THE FACILITY FOR THE COMING YEAR (FORM S1-3)	
Part A : 	Details of the facility (Note 1)	
1.	Facility name :
     	4.	Year of activities anticipated in this form
(i.e. the "reporting year", must be a calendar year) :      	
2.	Name of the owner, company or enterprise operating the above facility :
     	5.	Facility address :
	     
	     
	     	
(Please mark ‘X’ in one of the following and provide details) :
HKID no.  Passport no. BR no.:   	
other relevant registration no. (please specify) :      		
3.	Permit number :
     		Tel no. :      	Fax no. :      	
Part B :	Details of each Schedule 1 chemical anticipated to be produced in the facility (Please use a new Form S1-3 for each chemical)	
1.	IUPAC chemical name (Note 3) :
     	3.	Structural formula :
     	
2.	CAS registry no. (Note 4) :
     		
4.	Anticipated production (Note 5) quantity :

       	 grams

	6.	Purpose(s) to produce the above chemical (please mark ‘X’ if applicable) :
	 Research	
	 Medical	
	 Pharmaceutical
	 Production of other Schedule 1 chemicals
	 Waste disposal
	 Protective uses
	 Other (please specify) :      	
5.	Anticipated period of production (please provide dates in dd/mm/yy) :
Start date	:	       	

End date	:	       	

7.	Anticipated change at the facility and its relevant plant during the reporting year compared to previously submitted technical descriptions of the facility on Form S1:
	 Yes 	 No 	( please mark ‘X’) 

If yes, please submit Form S1 to provide updated information on the technical description of the facility.	
Part C :	Total number of Form S1-3 submitted (including this page) :          	 pages 
(Please submit Form S1 for Part B.7 if applicable. Also see Guideline 8)	
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 :