香港特別行政區政府
THE GOVERNMENT OF THE HONG KONG SPECIAL ADMINISTRATIVE REGION
除害劑條例 (第133章)
PESTICIDES ORDINANCE (CAP.133)
除害劑牌照申請表
(請填寫一式兩份)
APPLICATION FOR PESTICIDES LICENCE
(To be completed in duplicate)
第 I 部:	 一般資料
PART I:  GENERAL INFORMATION
公司名稱
Company Name		
公司地址
Company Address		
通訊地址 (如與上述不同)
Correspondence Address (if different from above)		
負責人姓名 (中文及英文)
Name of Responsible Person (Chi. & Eng.)	*先生／女士
*Mr./Ms.	
*香港身分證／護照號碼
*H.K. Identity Card/Passport No.		電話號碼
Phone No.		
電郵地址
Email Address		傳真號碼
Fax No.		
  * 請刪去不適用的項目  Please delete where not applicable
本人現申請除害劑牌照，其詳細資料如下**﹕
I hereby apply for a Pesticides Licence.  The detailed information is marked below**:	
				第I部

Part I	第I部 和
第II部
Part I & II		處所地址#
Address of Premises#	
	1.	輸入／供應Import/Supply							
	2.	售賣／零售
Sale/Retail							
	3.	貯存‡
Storage‡							
	4.	製造‡
Manufacture‡							
	5.	重新包裝‡
Repackaging‡					

**	請在適當的空格內加上 "" 號  Please tick as appropriate 
‡	請填寫附頁  Please fill in the supplement
# 	《除害劑條例》(第133章)("條例")第15A條賦予權力，可為確定條例是否已經或正在獲遵從而行使。其中權力包括督察或海關人員如合理地懷疑在此申請表中述明的任何處所或地方(不論是否住宅)內有製造、使用、存放、貯存、售賣、要約售賣或為售賣而展示、供應或要約供應除害劑的情況正在發生，該督察或人員可在任何合理時間，無需手令而進入該處所或地方。Powers under section 15A of the Pesticides Ordinance (Cap. 133) ("the Ordinance") may be exercised for the purpose of ascertaining whether the Ordinance has been or is being complied with.  Such powers include, amongst others, entry without a warrant by an inspector or a member of the Customs and Excise Service, at any reasonable time, of any premises or place (whether domestic or not) stated in this application form on which the inspector or member reasonably suspects a pesticide is being manufactured, used, kept, stored, sold, offered or exposed for sale, or supplied or offered to be supplied.
    
第 II 部:  除害劑牌照資料刊登同意書 
PART II:  CONSENT TO PUBLISH PESTICIDES LICENCE INFORMATION
	我同意^將我的公司名稱、獲批准處所的地址及牌照類別刊登於漁農自然護理署網頁及其他政府網頁上。我明白刊登此資料純屬自願性質，並非除害劑牌照申請的審批準則之一。 I consent to the publication of company name, address of approved premises and type of licence on the website of the Agriculture, Fisheries and Conservation Department and other government websites.  I understand that the publication is entirely voluntary and is not part of the assessment criteria for the application of Pesticides Licence.	

^ 若你同意，請在空格內加上 "" 號 Please put a tick in the box if you consent.

重要事項 
IMPORTANT NOTES 
�h	只有盛載在經批准的容器內的除害劑方能在本地售賣或供應。Pesticides must be kept in approved containers during local sale or supply.
�h	除害劑必須按照《除害劑規例》正確地貼上標籤。Pesticides must be properly labelled in accordance with the Pesticides Regulations.
�h	註冊除害劑的輸入、製造、售賣及供應，必須符合就該註冊除害劑所訂定的條件。有關註冊除害劑的條件可於本署網頁 www.afcd.gov.hk 瀏覽。The import, manufacture, sale and supply of a registered pesticide shall be subject to conditions imposed upon the registration of the pesticide, which are viewable on our website: www.afcd.gov.hk. 
�h	除害劑的輸入、製造、售賣及供應，必須按照相關除害劑牌照的條件而進行。The import, manufacture, sale and supply of a pesticide shall be subject to the conditions of the Pesticides Licence concerned. 

個人資料收集聲明 
PERSONAL INFORMATION COLLECTION STATEMENT
�h	你所提供的資料將用作申請本署的除害劑牌照、許可證或註冊的有關事宜。 The information provided by you will be used for purposes relating to the application for pesticides licence, permit or registration in this Department.
�h	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.
�h	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.
�h	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.  Please also quote your reference number in this Department.

本人現呈交下列文件 I submit the followings:
 有效商業登記證影印本  Photocopy of valid Business Registration Certificate
 東主證明(只適用於無限公司)  Ownership Proof (for unlimited company only)
 牌照費用 Licence Fee		
 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（請於此申請表第I部提供電郵地址以收取付款連結）Online payment: Credit card (Please provide an email address in Part I of this application form in order to receive a payment URL)	
如有任何查詢，歡迎致電 2150 7007與本署職員聯絡。For enquiries, please contact our staff at 2150 7007.

				
	(公司負責人簽署)
(Authorised Signature of Responsible Person 
for and on behalf of the Company)		(公司印鑑) 
(Company Chop) 	

	(職位)		(日期)	
	(Position in Company)		(Date)	
只供漁農自然護理署職員填寫  For official use only  ALIC:         Ref.: (     ) in AF GR PPR 01/    pt. 	
	
Corres. address	Yes / No / NA 		Licence Fee		Date		Signature		Mailed on	
Name (Chi.)			$	Recommended						
Name(Eng.)Mr./Ms.			Received on	by :					by :
	
ID/Passport No.			_____ /_____ /______	Endorsed						
 Signature	 ID Checked		Receipt No.	by :					Satisfactory
Inspection	
 BRC copy	 Corporation			Approved 
by :
					Date :	
Ownership Proof	Yes / No / NA		Licence No.							
 Part I	 Part I/II								by:	
Type (EISLM)