香港法例第207章植物(進口管制及病蟲害控制)條例
由中國內地輸入昆蟲害蟲授權書申請表
Plant (Importation and pest Control) Ordinance, Chapter 207
Form of Application for Authorization for Import of Insect Pests from Mainland China

　
注意事項：
  Notes　　　　    	1.	所有項目須以正楷填寫。
All items must be completed in block letters.	
	2.	此表格最好以英文填寫。
Appreciated if this form could be completed in English.	
	3.	請看背頁的個人資料收集聲明。
Please see overleaf for Personal Information Collection Statement.	
	4.	領取授權書方法：
Method of Authorization Collection :	
		  本辦事處2號櫃位。
  Over the Counter No.2 of this office.	
		  郵寄（惟申請時須連同有地址及郵票之回郵信封）。
  By mail (Please provide a self-addressed envelope with stamp during application.)	

　　
申請人姓名*		先生	Mr.								身分証號碼
Name of Applicant:	小姐	Miss								Identity Card No.	:        - - -     
                 		女士Ms.	_____________________	
公司名稱									 			商業登記証號碼
Name of Company: __________________________________			BRC No.: __________________________
地址													電話號碼
Address:	 _________________________________________________ 	Telephone No : ______________________

 昆蟲害蟲品種*
 Species of Insect Pests*
 	草蜢 / 麥皮蟲 / 蟋蟀 (蟋蟀品種：          )
Grasshopper / Mealworm / Cricket (Species :            )	
 每月進口次數
 No. of consignment to be imported per month
 		
 每次進口數量(隻數/公斤重量) 
 Quantity (Nos./kg) to be imported per consignment

 每月總入口數量(隻數/公斤重量)
 Total quantity to be imported per month (Nos./kg)
 		
來源地:				  		中國大陸經			 	  		海關進口站   	
Source/Origin: ____________________ 	Mainland China Via ____________________ 	C & E Entry Point	
預計抵港日期										運輸工具:	
Expected Date of Arrival: _____________________________		Mean of Conveyance _____________________

聲明: 本人聲明上述由中國大陸輸入昆蟲害蟲只可作雀鳥飼料用。
Declaration : I declare that the above Insect pests from Mainland China shall be used only for bird feed.

申請日期                          			申請人簽署            
Date of application: _________________________     	Signature of Applicant: _____________________________
* 請將不適用者刪去 Delete as appropriate 
此欄由本署填寫 For Official Use Only

     File Ref. of Auth.	      Auth. No.	    Prepared By	    Checked By	
 (       ) in AF PPR 11/6 Part (      ) 
				
PPRD11038B (7/2015)
香港漁農自然護理署		AGRICULTURE, FISHERIES            
       AND CONSERVATION DEPARTMENT
       OF HONG KONG 
	
個人資料收集聲明		Personal Information Collection Statement	
��	你所提供的資料將用作申請本署的植物進口證、授權書或植物檢疫證明書的有關事宜。		��	The information provided by you will be used for purposes relating to the application for plant import licence, authorization or phytosanitary certificate in this Department.	
��	本署可能會將你的資料或部份資料提供給任何代理商、承包商或其他政府部門作統計或調查之用途。		��	The said information or any part thereof may be supplied by this Department to any agent, contractor or other government departments for statistics or investigation purpose.	
��	除個人資料(私隱)條例所訂明的豁免外，你有權查閱和改正你的個人資料。		��	Subject to exemptions under the Personal Data (Privacy) Ordinance, you have a right of access and correction with respect to personal data.	
��	查閱和改正個人資料的要求應以書面形式向漁農自然護理署署長提出，地址為香港九龍長沙灣道三零三號長沙灣政府合署五樓，同時請註明你在本署的檔案號碼。		��	Request for personal data access and correction should be addressed to Director of Agriculture, Fisheries and Conservation at 5/F., Cheung Sha Wan Government Offices, 303 Cheung Sha Wan Road, Kowloon, Hong Kong.  Please also quote your reference number in this Department.	

Checklist for information provided by the applicant
申請人資料遞交核對表
	本人已填寫個人/公司資料。
I have already filled in my personal particulars / company details.	
	本人已申報進口的昆蟲害蟲名稱及其數量。
I have already provided the species and quantity(ies) of the insect pest(s) to be imported.	
	本人已提供該批昆蟲害蟲的來源地。
I have already provided the origin of the insect pest(s) to be imported.	
	這申請是本人於該批昆蟲害蟲貨到前向貴署提出的。
This application is submitted by me before the shipment arrival of the insect pest(s).	
	本人已在申請表上簽署。
I have already signed my name on the application form.