植物檢疫證明書申請表 (香港漁農自然護理署)
Form of Application for Phytosanitary Certificate (AFCD, Hong Kong)

出口商名稱及地址
Name & address of exporter		

電郵地址
Email address		電話號碼
Phone no.		
收貨人名稱及地址
Name & address of consignee		
件數及包裝說明 
Number & description of package		
顯著之標誌
Distinguishing marks		
來源地(生長於)
Origin (Grown at)		離港運輸方法
Means of conveyance for departure		
輸入港口
Port of entry		最終入口國家
Country of Destination		截倉/離港日期
Closing/ Departure date		
產品名稱及數量
Name of produce & quantity		
總共
Total		
植物學名
Botanical Name		
繳費方法 Payment methods		   親身繳交：現金、劃線支票（抬頭請註明「香港特別行政區政府」）或易辦事  
In person: Cash, Crossed cheque (made payable to “The Government of the HKSAR”) or EPS
   郵遞：劃線支票（抬頭請註明「香港特別行政區政府」）
By post: Crossed cheque (made payable to “The Government of the HKSAR”)
   網上繳費：信用卡（請於此申請表提供電郵地址以收取付款連結）
Online payment: Credit card (Please provide an email address on this application form in order to receive a payment URL)	

有關瀕危品種的聲明	: 本人聲明此乃   * 野生/栽培   之瀕危植物或植物產品 (*請將不適用者刪去)

是
Yes

Declaration on Endangered Species:	I declare that the endangered plants(s)/plant product(s) is/are  * wild/artificially propagated  species or variety(ies). (*Delete as appropriate)
□
	□否
No	本人同時申請以植物檢疫證明書作為瀕危植物出口許可證（請參照以下注意第2點，如適用的話，請在空格註上「」號）
I would also like to apply for using the phytosanitary certificate as a CITES Licence to Export for endangered plants (Please refer to Note 2 below and tick the box if appropriate)	

附加聲明Additional declaration

申請人簽署
Signature of Applicant	
驗貨地點／日期
Location/Date of consignment to be examined	姓名請用正楷
Name (in BLOCK LETTERS)	
	日期 
Date 	
( 注意 ) Note
1. 假若貨主由申請日期起三個月內仍未能安排貨物給漁農自然護理署檢驗，本署可拒絕驗貨，惟並無任何賠償或退款。
If the consignment cannot be arranged by the applicant for inspection within 3 months from the date of application, Agriculture, Fisheries and Conservation Department may refuse to conduct the inspection without any refund or compensation.
2. 出口或再出口瀕危植物，出口商須持有本署發出之瀕危物種出口/再出口許可證。若是出口產自香港的人工培植的附錄II植物的標本，申請人可申請以植物檢疫證明書作為瀕危物種出口許可證。請致電(852) 2150 6974向瀕危物種保護科查詢詳情。
Export or re-export of endangered plants requires a CITES Licence to Export/Re-export issued by this Department. For export of specimens of Appendix II plants artificially propagated in and originated from Hong Kong, applicant may apply for using the phytosanitary certificate as a CITES Licence to Export.  Please contact the Endangered Species Protection Division at Tel. (852) 2150 6974 for details.
3. 如有關填寫此申請表上的問題，請致電(852) 2150 7000與本署植物及除害劑監理科聯絡。
For any enquiries on filling this form, please contact Plant & Pesticides Regulatory Division at (852) 2150 7000.
# 請看背頁的個人資料收集聲明。       Please see overleaf for Personal Information Collection Statement.     		
==========================================================================================================
曾否使用熏蒸消毒或普通消毒（如有者）  Fumigation or disinfection treatment (if any) 

日期Date	
處理時間多長 Duration of exposure	

葯劑及濃度Chemical & concentration	
處理方法 Treatment	

此欄由本署填寫 FOR OFFICIAL USE ONLY
	
Item	
(     )                            	
(     )           	
Application Date
	Receipt No.	Inspection Date	Inspected by	Prepared by	I.F.	$ 	$	
P.C. No.
	Date Issued	Result of Inspection
OK         See Overleaf	V.F.	$	
Transferred To	 Remarks	Checked By	Input By	

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、植物檢疫證明書或瀕危物種出口／再出口許可證的有關事宜。		��	The information provided by you will be used for purposes relating to the application for plant import licence, authorization, phytosanitary certificate or a CITES Licence to Export / Re-export 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，你有權查閱和更改你的個人資料。		��	Subject to exemptions under the Personal Data (Privacy) Ordinance, you have a right of access and correction with respect to your personal data.	
��	查閱和更改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303號長沙灣政府合署5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.	
	本人已填寫收貨人的名稱及地址。
I have already filled in the name and address of consignee.	
	本人已申報產品名稱、數量及植物學名。
I have already provided the name(s), quantity(ies) and the botanical name(s) of the produce(s) to be exported.	
	本人已申報該批產品的包裝件數及包裝說明。
I have already provided the number and description of package.	
	本人已提供該批產品的來源地、輸入港口、離港運輸方法、截倉/離港日期及入口國家。
I have already provided the origin of produce, port of entry, means of conveyance for departure, country of destination and closing/departure date.	
	本人已提供該批產品使用熏蒸消毒或普通消毒的資料（如有者）。
I have already provided the information of fumigation or disinfection treatment for the consignment (if any).	
	本人已聲明該批產品是野生/栽培的瀕危植物品種（如有者）。
I have already declared the consignment of plant(s) is/are wild/artificially propagated (if any).	
	本人已申請以植物檢疫證明書作為瀕危物種出口許可證（如適用者）。
I have already applied for using the phytosanitary certificate as a CITES Licence to Export for endangered plants (if applicable).	
	本人已在申請表上簽署。
I have already signed my name on the application form.