Annex C of Section C
SCHEDULE 1 DECLARATION FORMS
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Form C-1 Country Code:
Section: C
Initial Declaration of existing Schedule 1
Page of n pages:
facilities Date (ccyy-mm-dd):
Confid. Please indicate to which Schedule 1 facility this
mark declaration relates:
Single small-scale facility (SSSF): Yes No
Other facility for protective purposes: Yes No
Other facilities for research, medical or pharmaceutical
purposes: Yes No
Please complete Attachment I to the C forms to declare
the SSSF and Attachment II to the C forms to declare
other Schedule 1 Facilities.
Version 2008
Form C-2 Country Code:
Section: C
Initial Declaration of new Schedule 1
Page of n pages:
facilities Date (ccyy-mm-dd):
Confid. Please indicate to which Schedule 1 facility this
mark declaration relates:
Single small-scale facility (SSSF): Yes No
Other facility for protective purposes: Yes No
Other facilities for research, medical or pharmaceutical
purposes: Yes No
Please complete Attachment I to the C forms to declare
the SSSF and Attachment II to the C forms to declare
other Schedule 1 Facilities.
Version 2008
Form C-3 Country Code:
Section: C
Annual declaration of Schedule 1
Page of n pages:
chemicals and activities at Schedule 1 Date (ccyy-mm-dd):
facilities during the previous year
Confid. Please indicate to which Schedule 1 activity or facilities
mark this declaration relates:
Schedule 1 chemical that has been transferred Yes No
Single small-scale facility (SSSF): Yes No
Other facility for protective purposes: Yes No
Other facilities for research, medical or pharmaceutical
purposes: Yes No
Please complete Attachment I to the C forms to declare
any changes at the SSSF and Attachment II to the C
forms to declare any changes at other Schedule 1
Facilities.
Version 2008
Form C-4 Country Code:
Section: C
Annual Declaration of projected
Page of n pages:
activities and anticipated production Date (ccyy-mm-dd):
Confid. Please indicate to which Schedule 1 facilities this
mark declaration relates:
Single small-scale facility (SSSF): Yes No
Other facility for protective purposes: Yes No
Other facilities for research, medical or pharmaceutical
purposes: Yes No
Please complete Attachment I to the C forms to declare
any anticipated changes at the SSSF and Attachment II
to the C forms to declare any anticipated changes at
other Schedule 1 Facilities.
Version 2008
Attachment I to C Forms Country Code:
Section: C
Declaration of the Single Small-Scale
Page of n pages:
Facility Date (ccyy-mm-dd):
Confid.
mark
Single small-scale facility (SSSF) code:
Name of the facility:
Name of the operator of the facility:
Building or structure number, if any:
Street address of facility:
Latitude, longitude/Precise location:
Identify the attachments for additional information on this
facility:
Please provide the following, as attachments, for the
detailed technical description of the facility and identify
the information attached
(i) Narrative
(ii) Detailed diagrams
(iii) Inventory of the equipment
(iv) Volume in litres of largest reactor vessel
(v) Total volume in litres of all reactor vessels exceeding
a volume of 5 litres
Version 2008
Attachment II to C Forms Country Code:
Section: C
Declaration of other Schedule 1 facilities
Page of n pages:
Date (ccyy-mm-dd):
Confid. Please complete one form for each facility to be declared.
mark
Other facility for protective purposes: Yes No
Other facilities for research, medical or pharmaceutical
purposes: Yes No
Facility code:
Name of the facility:
Name of the operator of the facility:
Building or structure number, if any:
Street address of facility:
Latitude, longitude/Precise location:
Identify the attachments for additional information on this
facility:
Please provide the following, as attachments, for the
detailed technical description of the facility or its relevant
parts and identify the information attached
(i) Narrative
(ii) Detailed diagrams
(iii) Inventory of the equipment
Version 2008
Form CN-1 Country Code:
Section: C
Primary Notification of Schedule 1
Page of n pages:
Chemicals and Facilities: Advance Date (ccyy-mm-dd):
Notification of Planned Changes to the
Initial Declaration of Declared Facilities
Confid. Please indicate to which Schedule 1 facilities this
mark declaration relates:
Single small-scale facility (SSSF): Yes No
Other facility for protective purposes: Yes No
Other facilities for research, medical or pharmaceutical
purposes: Yes No
Please complete Attachment I or II to the C forms to
indicate the planned changes to the initial declaration.
Version 2008
Form CN-2 Country Code:
Section: C
Notifications for Transfers of Schedule 1
Page of n pages:
Chemicals: Notification of a Planned Date (ccyy-mm-dd):
Transfer to or from the Notifying State
Party
Confid.
mark
Please indicate whether this is a notification of
the supply or receipt of a Schedule 1 chemical (indicate Supply Receipt
one only):
Please complete Attachment I to Form CN-2 to specify
this transfer.
Version 2008
Attachment I to Form CN-2 Country Code:
Section: C
Detailed Notification of a Planned
Page of n pages:
Transfer of a Schedule 1 Chemical to or Date (ccyy-mm-dd):
from the Notifying State Party
Confid. Provide the following information for each individual
mark planned transfer.
IUPAC chemical name:
Identify the attachment for structural formula, if not
contained in the handbook for chemicals:
CAS registry number:
Quantity involved:
Planned date of transfer:
Purpose of transfer (use C01 to C06 of Appendix 8 codes
or specify)
Please identify the source of the Schedule 1 chemical
Source country:
Name:
Street address:
Please identify the recipient of the Schedule 1 chemical
Recipient country:
Name:
Street address:
Version 2008
Form 1.1 Country Code:
Section: C
Annual Declaration of Schedule 1
Page of n pages:
Chemicals at the SSSF as well as at Date (ccyy-mm-dd):
Other Schedule 1 Facilities during the
Previous Year
Confid. Please complete one form for each Schedule 1 chemical
mark that was produced, consumed or stored at the SSSF as
well as other Schedule 1 facilities.
Facility code:
IUPAC chemical name:
Identify the attachment for structural formula, if not
contained in the handbook for chemicals:
CAS registry number:
Total amounts of the Schedule 1 chemical produced,
consumed or stored at the facility
Unit of weight: Kg g
Quantity Produced:
Production methods employed:
(required only for the SSSF and the "other facility for
protective purposes")
Quantity consumed:
Purposes of consumption (use C01 to C06 of Appendix 8
codes or specify):
Total quantity received from other facilities in the State
Party (required only for SSSF):
Total quantity of the Schedule 1 chemical supplied to
other facilities in the State Party:
Maximum quantity of the Schedule 1 chemical stored at
any time during the previous year:
Quantity of the Schedule 1 chemical stored at the end of
the previous year:
Version 2008
Form 1.1.1 Country Code:
Section: C
Annual Declaration of Schedule 1
Page of n pages:
Chemicals at the SSSF and Other Date (ccyy-mm-dd):
Schedule 1 Facilities: Name and
Quantity of Precursors Listed in
Schedule 1, 2 or 3 Used for the
Production of Schedule 1 Chemicals
Confid. Please use this form to declare all precursor scheduled
mark chemicals used for each Schedule 1 chemical produced at
the facility.
Facility code:
IUPAC chemical name of the Schedule 1 chemical
produced:
CAS registry number of the Schedule 1 chemical
produced:
Please repeat the following block of information as many
times as necessary to declare all scheduled precursor
chemicals used for the production of each Schedule 1
chemical at the facility.
IUPAC chemical name for a precursor scheduled
material:
CAS registry number for a precursor scheduled material:
Quantity of precursor scheduled chemical used:
IUPAC chemical name for a precursor scheduled
material:
CAS registry number for a precursor scheduled material:
Quantity of precursor scheduled chemical used:
IUPAC chemical name for a precursor scheduled
material:
CAS registry number for a precursor scheduled material:
Quantity of precursor scheduled chemical used:
IUPAC chemical name for a precursor scheduled
material:
CAS registry number for a precursor scheduled material:
Quantity of precursor scheduled chemical used:
Version 2008
Version 2008
Form 1.1.2 Country Code:
Section: C
Annual Declaration of Schedule 1
Page of n pages:
Chemicals at the SSSF: Transfer of Date (ccyy-mm-dd):
Schedule 1 Chemical to or from Other
Facilities within the State Party
Confid.
mark
Facility code:
Please repeat the following block of information as many
times as necessary to declare all transfers for the
Schedule 1 chemicals from or to the SSSF within a State
Party.
IUPAC chemical name:
CAS registry number:
Please specify whether the Schedule 1 chemical was
received or supplied: Received Supplied
Quantity involved:
Name of other facility involved:
Street address:
Specify purposes of transfer (use C01 to C06 of
Appendix 8 codes or specify):
IUPAC chemical name:
CAS registry number:
Please specify whether the Schedule 1 chemical was
received or supplied: Received Supplied
Quantity involved:
Name of other facility involved:
Street address:
Specify purposes of transfer (use C01 to C06 of
Appendix 8 codes or specify):
Version 2008
Form 1.1.3 Country Code:
Section: C
Annual Declaration of Other Schedule 1
Page of n pages:
Facilities: Supply of Schedule 1Chemical Date (ccyy-mm-dd):
to Other Facilities within the State Party
Confid.
mark
Facility code:
Please repeat the following block of information as many
times as necessary to declare all transfers of Schedule 1
chemicals to other facilities.
IUPAC chemical name:
CAS registry number:
Quantity involved:
Name of other facility involved:
Street address:
Specify purposes of supply (use C01 to C06 of
Appendix 8 codes or specify):
IUPAC chemical name:
CAS registry number:
Quantity involved:
Name of other facility involved:
Street address:
Specify purposes of supply (use C01 to C06 of
Appendix 8 codes or specify):
IUPAC chemical name:
CAS registry number:
Quantity involved:
Name of other facility involved:
Street address:
Specify purposes of supply (use C01 to C06 of
Appendix 8 codes or specify):
Version 2008
Form 1.2 Country Code:
Section: C
Detailed Annual Declaration of
Page of n pages:
Transfers to or from the Declaring State Date (ccyy-mm-dd):
Party During the Previous Year
Confid.
mark
IUPAC chemical name:
Identify the attachment for structural formula, if not
contained in the Handbook for Chemicals:
CAS registry number:
Unit of weight: Kg g
Please repeat the following block of information to
declare all transfers of Schedule 1 chemicals.
Country Codes (see Appendix 1):
Total Quantity received:
Total Quantity supplied:
Country Codes (see Appendix 1):
Total Quantity received:
Total Quantity supplied:
Country Codes (see Appendix 1):
Total Quantity received:
Total Quantity supplied:
Country Codes (see Appendix 1):
Total Quantity received:
Total Quantity supplied:
Version 2008
Form 1.2.1 Country Code:
Section: C
Detailed Annual Declaration of Each
Page of n pages:
Transfer of Schedule 1 Chemicals Date (ccyy-mm-dd):
Confid. Please complete one form for each individual transfer of
mark Schedule 1 chemicals supplied or received.
Was the Schedule 1 chemical received or supplied by the
declaring State Party? (Please indicate one) Received Supplied
IUPAC chemical name:
CAS registry number:
Source country (use country codes, see Appendix 1):
1
Name of source:
Street address:
Recipient country (use country codes, see Appendix 1):
Name of recipient:
Street address:
Please specify purposes of transfer (use C01 to C06 of
Appendix 8 codes or specify):
Quantity transferred:
Date of transfer:
1 Paragraph 6 of Part VI of the Verification Annex requires the recipient to be declared but does not require the
source. However, many States Parties provide information on the source on a voluntary basis.
Version 2008
Form 1.3 Country Code:
Section: C
Declaration of Projected Activities and
Page of n pages:
Anticipated Production of Schedule 1 Date (ccyy-mm-dd):
Chemicals at the SSSF
Confid. Please repeat the following information as many times as
mark necessary to declare all Schedule 1 chemicals anticipated
to be produced, consumed or stored at the SSSF.
Facility code:
IUPAC chemical name:
Identify the attachment for structural formula, if not
contained in the Handbook for Chemicals:
CAS registry number:
It is anticipated that this Schedule 1 chemical will be:
Produced: Yes No
Consumed: Yes No
Stored: Yes No
Anticipated production quantity:
Purposes of the anticipated production (use C01 to C06 of
Appendix 8 codes or specify):
IUPAC chemical name:
Identify the attachment for structural formula, if not
contained in the Handbook for Chemicals:
CAS registry number:
It is anticipated that this Schedule 1 chemical will be:
Produced: Yes No
Consumed: Yes No
Stored: Yes No
Anticipated production quantity:
Purposes of the anticipated production (use C01 to C06 of
Appendix 8 codes or specify):
Version 2008
Form 1.4 Country Code:
Section: C
Declaration of Projected Activities and
Page of n pages:
Anticipated Production of Schedule 1 Date (ccyy-mm-dd):
Chemicals at Other Schedule 1 Facilities
Confid. Please repeat the following information as many times as
mark necessary to declare all time periods for the production of
Schedule 1 chemicals at other Schedule 1 facilities.
Facility code:
IUPAC chemical name:
Identify the attachment for structural formula, if not
contained in the Handbook for Chemicals:
CAS registry number:
Anticipated quantity to be produced:
Anticipated periods of production:
Purposes of the anticipated production (use C01 to C06 of
Appendix 8 codes or specify):
IUPAC chemical name:
Identify the attachment for structural formula, if not
contained in the Handbook for Chemicals:
CAS registry number:
Anticipated quantity to be produced:
Anticipated periods of production:
Purposes of the anticipated production (use C01 to C06 of
Appendix 8 codes or specify):
IUPAC chemical name:
Identify the attachment for structural formula, if not
contained in the Handbook for Chemicals:
CAS registry number:
Anticipated quantity to be produced:
Anticipated periods of production:
Purposes of the anticipated production (use C01 to C06 of
Appendix 8 codes or specify):
Version 2008
Version 2008
