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)

除害劑許可證申請表 (請填寫一式兩份)

APPLICATION FOR PESTICIDES PERMIT
(To be completed in duplicate)

[填寫本申請表前，請參閱“申請除害劑許可證指南”及“附錄A – 申請除害劑許可證所需資料摘要”]
[Before completing this application form, please read the “Guide to Application for a Pesticides Permit” and “Appendix A - Information Required for Applying for a Pesticides Permit”]

第I部:	申請人資料
PART I:	PARTICULARS OF APPLICANT
公司名稱
Company Name	中文 Chinese		
	英文 English		
公司地址
Company Address		
通訊地址 (如與上述不同)
Correspondence Address 
(If different from above)		

負責人資料
PARTICULARS OF THE RESPONSIBLE PERSON
姓名
Name	中文 Chinese	*先生／女士	
	英文 English	*Mr. / Ms.	
*香港身份證／護照號碼
*H.K. Identity Card / Passport No.		
職位 Position in Company		
電話號碼 Phone No.		傳真號碼 Fax No.		
電郵地址 Email Address		
  *請刪去不適用的項目  Please delete where not applicable

除害劑處理人資料  (如與負責人不同)
PARTICULARS OF THE PESTICIDE HANDLER (If different from the Responsible Person)
姓名
Name	中文 Chinese	*先生／女士	
	英文 English	*Mr. / Ms.	
*香港身份證／護照號碼
*H.K. Identity Card / Passport No.		
職位 Position in Company		
電話號碼 Phone No.		傳真號碼 Fax No.		
電郵地址 Email Address		
第II 部:	除害劑資料摘要
PART II:	SUMMARY OF INFORMATION ON THE PESTICIDE
商標／產品名稱
Brand / Product Name		
活性成分通用名稱(1)
(ISO或ANSI或BSI)#
Common Name(s) of Active
Ingredient(s)(1)
(ISO or ANSI or BSI)#		
活性成分化學名稱 (IUPAC)#
Chemical Name(s) of Active
Ingredient(s) (IUPAC)#		
活性成分濃度及單位(1)**
Concentration(s) and Unit(s) of
Active Ingredient(s)(1)**		□ 重量／重量百分比 (% w/w)
□ 重量／體積百分比 (% w/v)
□ 其他Others 	
劑型類別 (劑型縮寫)(2)
Type of Formulation 
(Formulation Abbreviation)(2)		(             )	
除害劑類別**
Type of Pesticide**	□ 除蟎劑   Acaricide
□ 除藻劑   Algicide
□ 防蠔漆   Antifouling Paint
□ 除真菌劑 Fungicide
□ 除草劑   Herbicide
□ 除蟲劑   Insecticide	□ 殺螺劑     Molluscicide
□ 殺線蟲劑   Nematicide
□ 殺鼠劑     Rodenticide
□ 實驗室用途 Laboratory Use
□ 其他       Others 	
附表所列除害劑**
Scheduled Pesticide**	□ 附表1
□ 附表2第1部
□ 不適用	Schedule 1
Part 1 of Schedule 2
N.A.	
輸入目的
Purpose of Import		
預計首批除害劑付運日期及數量
Intended Date & Quantity of 
the First Shipment		
除害劑包裝
Packaging of Pesticide		
** 請在適當的空格內加上“”號  Please tick as appropriate

(1) 如有多於一種活性成分，請以符號“／”分隔每種成分的相關資料 (例如: A/B/C)
If there are more than one active ingredient, please use the symbol “/” to separate the related information on each ingredient (e.g. A/B/C)
(2) 劑型類別及縮寫請瀏覽漁護署網頁
Please refer to AFCD’s website for type of formulation and abbreviation

# 縮寫Abbreviations:	ANSI  	= 美國國家標準協會	American National Standards Institution	
	BSI   	= 英國標準協會	British Standards Institution	
	ISO   	= 國際標準化組織	International Organization for Standardization	
	IUPAC 	= 理論化學和應用化學國際聯會 	International Union of Pure and Applied Chemistry	

第III部:	除害劑許可證類別
PART III:	TYPE OF PESTICIDES PERMIT
本申請是為在下述地址就第II部所述的附表所列除害劑／未經註冊除害劑擬進行有關活動而提出**：
This application is made in respect of the scheduled/unregistered pesticide set out in Part II above for the following intended activities to be carried out at address(es) specified below**:	
			處所地址Address of Premises	
I.		輸入
Import		於
at			
II.		製造 (包括重新包裝)
Manufacture (including repackaging)		於
at			
III.		售賣
Sale		於
at			
IV.		供應
Supply		於
at			
V.		管有
Possession		於
at			
VI.		使用
Use		於
at			
VII.		貯存
Storage		於
at			
VIII.		出口 (只適用於附表所列除害劑)
Export (for scheduled pesticides only)		於
at			
IX.		轉運 (只適用於附表所列除害劑)
Transhipment (for scheduled pesticides only)		於
at			
						
** 請在適當的空格內加上“”號  Please tick as appropriate

重要事項IMPORTANT NOTES	
��	請確保已遞交“附錄A – 申請除害劑許可證所需資料摘要”提及的一切所需資料及證明文件。
Please ensure that all the necessary information and supporting documents as required in “Appendix A –Information Required for Applying for a Pesticides Permit” are submitted.

��	《除害劑條例》(第133章)第15A條賦予的權力，可為確定該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本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) 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.

��	為遵守世界貿易組織《與貿易有關的知識產權協議》第39(3)條的規定並在該條的規限下，所有得來不易的未公布測試資料或其他資料在送交漁農自然護理署作申請除害劑許可證用途後會：
-	被視作機密資料並加以保密；
-	只限數名因有關的除害劑許可證申請而有需要知道該等資料的政府人員查閱；以及
-	除非獲原資料的供應者書面授權，否則有關資料永不用於其他許可證申請。
In compliance with and subject to the provisions of Article 39(3) of the Agreement on Trade-Related Aspects of Intellectual Property Rights under the World Trade Organization, all data relating to undisclosed tests or other data, the origination of which involves a considerable effort, upon being submitted to the Agriculture, Fisheries and Conservation Department for the purpose of applying for a Pesticides Permit, are:
-	considered and kept confidential;
-	only viewed by a limited number of Government officers on a need-to-know basis for the application for Pesticides Permits; and
-	never used in other permit applications unless under written authorisation from the supplier of the original data.

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除害劑許可證的有關事宜。
The information provided by you will be used for purposes relating to the application for Pesticides Permit in this Department.

��	除那些得來不易的未公布測試資料或其他資料外，本署可向任何代理人、承辦商或其他政府部門提供上述個人資料或其任何部分，以供作除害劑許可證申請的統計或調查用途。
Except for data relating to undisclosed test or other data, the origination of which involves a considerable effort, the said personal data or any part thereof may be supplied by this Department to any agent, contractor or other government departments for statistics or investigation purpose in relation to the application of Pesticides Permit.

��	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.	

第IV部:	聲明
PART IV:	DECLARATION
��	在申請此除害劑許可證時，本人明白倘申請獲批准，本人將要對此許可證負上責任，並且將要遵守許可證內所列出的全部條件。本人現呈交下列項目：
In applying for a Pesticides Permit, I understand that if this application is approved, I shall be responsible for the permit and shall comply with all the conditions set out on the permit. I submit the following items:
 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)
 申請費用 Application 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)

��	本人已閱讀及完全明白本申請表內的“重要事項”及“個人資料收集聲明”。
I have read and fully understood the “Important Notes” and “Personal Information Collection Statement” in this application form. 

公司印鑑
Company Chop

公司負責人簽署
Signature of Responsible Person
for and on behalf of the Company		
負責人姓名
Name of Responsible Person		
職位
Position in Company		
日期
Date		

只供漁農自然護理署職員填寫For AFCD Official Use Only

Form Received Date	DD/MM/YYYY	By Hand By Post By Email	
Record No.	PPA		
Application Date	DD/MM/YYYY		
Application Fee	$		
Receipt No.			
File Reference	(    ) in AF GR PPR       Pt.(  )		
Issue Fee Payment Date	DD/MM/YYYY		
Issue Fee	$		
Receipt No.			

	香港特別行政區政府漁農自然護理署
THE GOVERNMENT OF THE HONG KONG SPECIAL ADMINISTRATIVE REGION
AGRICULTURE, FISHERIES AND CONSERVATION DEPARTMENT	

附錄A－申請除害劑許可證所需資料摘要
Appendix A － Information Required for Applying for a Pesticides Permit

注意事項 NOTES:
��	如提交的報告及資料的原文是中、英文以外的語文，申請人必須一併提供有關文件的經核證中文或英文譯本。
If the original report and information are written in a language other than Chinese and English, the applicant should submit their certified English or Chinese translations.	

A.	有關除害劑毒性的資料
INFORMATION ON TOXICITY OF THE PESTICIDE

1.	活性成分及配方製品的急性毒性：-
Acute toxicity of active ingredient(s) and formulated product:-
a.	急性口服毒性(半數致死劑量) acute oral toxicity (LD50)
b.	急性皮膚毒性(半數致死劑量) acute dermal toxicity (LD50) 
c.	吸入毒性(半數致死濃度) inhalation toxicity (LC50)
d.	對眼睛的刺激程度 degree of irritation to eyes
e.	對皮膚的刺激／致敏程度 degree of skin irritation / sensitisation
2.	活性成分的慢性毒性研究(長期／短期)：-
Chronic toxicity studies (long / short term) of active ingredient(s) on:-
a.	致癌作用 carcinogenicity
b.	對生育的毒性，包括致畸作用 reproductive toxicity including teratogenicity
c.	致突變作用 mutagenicity
d.	對神經的毒性 neurotoxicity

B.	對活性成分／配方製品的分析方法 
METHOD OF ANALYSIS OF THE ACTIVE INGREDIENT(S) / FORMULATED PRODUCT

C.	活性成分的環境研究資料
INFORMATION ON ENVIRONMENTAL STUDIES OF THE ACTIVE INGREDIENT(S)

1.	在泥土中的新陳代謝、有氧及無氧代謝物和分解物
Metabolism in soil, aerobic and anaerobic metabolites and breakdown products

2.	在水中的生物降解情況、有氧及無氧代謝物和分解物
Biodegradation in aquatic systems, aerobic and anaerobic metabolites and breakdown products
3.	活性成分對非目標生物的毒性
Toxicity of active ingredient(s) on non-target organisms

D.	原裝產品標籤
ORGINIAL PRODUCT LABEL

E.	由製造商或供應商就活性成分及產品提供的物料安全資料表
MATERIAL SAFETY DATA SHEET OF ACTIVE INGREDIENT(S) AND PRODUCT AS PROVIDED BY THE MANUFACTURER OR SUPPLIER

該獨立文件應包含下列資料：
The self-contained document should comprise the following information:
1.	製造商名稱及地址 Manufacturer name and address
2.	通用名稱Common name(s) (ISO或or ANSI或or BSI)
3.	化學名稱Chemical name(s) (IUPAC)
4.	化學文摘社登記號碼 CAS No.
5.	除害劑組別Pesticide group
6.	其他名稱(商標／產品名稱) Other name (Brand / Product name)
7.	劑型 Formulation
8.	活性成分濃度及單位Concentration(s) and unit(s) of active ingredient(s)
9.	物理特性Physical properties:-
a.	溶點melting point
b.	沸點boiling point
c.	比重specific gravity
d.	蒸氣壓力(在20C時氣壓為    毫米汞柱) vapor pressure (    mmHg at 20C)
e.	其他有關揮發性的資料other volatility data
f.	在水中的可溶性solubility in water
g.	外觀和氣味 appearance and odour
h.	其他詳情 others
10.	化學特性Chemical properties:-
a.	穩定性 (在空氣及水中的穩定性、光穩定性、熱化降解) 
stability (stability in air and water, photostability, thermal degradation)
b.	腐蝕性corrosiveness
c.	閃點flash point
d.	可燃性flammability
e.	其他詳情others
11.	滅火措施 Fire-fighting measures:-
a.	滅火劑extinguishing media
b.	特殊滅火程序special fire-fighting procedures
c.	給消防人員的建議advice for firefighters
12.	危害辨識 Hazard identification
13.	急救措施 First-aid measures
14.	解毒劑 Antidote(s)
15.	淨化／中和劑 Decontamination / neutralisation agent(s)
16.	暴露防範措施 Exposure precautions:-
a.	眼睛防護eye protection
b.	呼吸防護respiratory protection
c.	皮膚及身體防護skin and body protection
d.	其他詳情others
17.	處理和貯存方法Handling and storage methods
18.	泄漏處理程序Spillage or leakage handling procedures
19.	棄置方法Disposal methods

F.	使用除害劑須提交的資料 (中英對照)
INFORMATION REQUIRED FOR USE OF THE PESTICIDE (BILINGUAL)

1.	已在該除害劑的註冊國家獲批准的產品標籤、註冊證明書及小冊子(例如註冊編號、註冊限制、註冊條件等)
Approved label, registration certificates and product brochure (e.g. registration no., registration restrictions, registration conditions) in the countries where the pesticide has been registered
2.	建議用途(例如使用方式、施用地點、施用次數等)
Recommended uses (e.g. use pattern, application sites and application frequency)
3.	使用說明(例如施用方法和劑量)
Instructions for use (e.g. application method and dosage)
4.	泄漏處理程序
Spillage or leakage handling procedures
5.	個人保護裝備
Personal protective equipment
6.	不可使用該除害劑的特殊情況
Special conditions under which the pesticide must not be used
7.	標籤上載列的注意事項
Precautionary statements on the label
8.	所針對的目標生物
Target organism(s)
9.	對蟲害的防治效果(例如經接觸、吸入或消化中毒、內吸作用、殺真菌毒性等)
Effects on pests (e.g. contact, inhalation or stomach poison, systemic, fungitoxic etc.)
10.	作用模式
Mode of action
11.	植物藥性(只限於向植物施用的除害劑)
Phytotoxicity (for pesticides to be applied on plants only)
12.	與其他除害劑的相容性
Compatibility with other pesticides
13.	在密閉環境施用的除害劑：可再進入的相隔時間
For pesticides to be applied in confined areas: Re-entry lapse time
14.	擬施用於糧食作物的除害劑:-
For pesticides intended for use on food crops:-
a.	收成前的安全間隔期
pre-harvesting interval
b.	註冊國家所訂明該除害劑的最高殘餘限量及每日可攝入量
maximum residue limit and acceptable daily intake as specified in the countries where the pesticide has been registered
c.	《公眾衞生及市政條例》(第132章)下的《食物內除害劑殘餘規例》附表所載有關該除害劑最高殘餘限量(如該除害劑獲豁免遵守這項規定，亦請說明)的資料
information on the maximum residue limit (MRL) of the pesticide (please specify in case the pesticide is exempted from the requirement) in the Schedules of the Pesticide Residues in Food Regulation under the Public Health and Municipal Services Ordinance (Cap.132)

G.	在本地製造和重新包裝除害劑須提交的資料 
INFORMATION REQUIRED FOR LOCAL MANUFACTURE AND REPACKAGING OF PESTICIDES

1.	擬使用的化學品Chemicals to be used
2.	劑型Formulation(s)
3.	設施及器材Facilities and equipment
4.	年產量Annual production
5.	製造／重新包裝目的(例如出口) Purpose of manufacture / repackaging (e.g. export )
6.	製造及重新包裝方法的詳情 Details of method of manufacture and repackaging
7.	由下述部門發出的批准文件 Approval document(s) issued by:-
a.	環境保護署Environmental Protection Department
b.	消防處 Fire Services Department
c.	地政總署 Lands Department
d.	其他 Other(s)