香港特別行政區政府
除害劑條例（第133章）
THE GOVERNMENT OF THE HONG KONG SPECIAL ADMINISTRATIVE REGION
PESTICIDES ORDINANCE (CAP. 133)

除害劑註冊申請表
APPLICATION FORM FOR PESTICIDE REGISTRATION

[填寫此申請表前，請參閱“除害劑註冊申請指南”及“附件A－除害劑註冊所需資料”]
[Before filling this application form, please read “A Guide to Application for Pesticide Registration” and 
“Appendix A - Information Requirement for Pesticide Registration”]

第I部： 申請人資料
PART I:  APPLICANT INFORMATION

申請人名稱
(公司／個人)
Name of Applicant (Company / Person)	(中文 Chinese)		
	(英文 English)		
申請人地址
(公司／個人)
Address of Applicant 
(Company / Person)	(中文 Chinese)		
	(英文 English)		
公司負責人姓名
Name of Company Responsible Person	(中文 Chinese)		
	(英文 English)		
聯絡人姓名
Name of Contact Person	(中文 Chinese)		
	(英文 English)		
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 PESTICIDE

商標／產品名稱
Brand / Product Name	(中文 Chinese)		
	(英文 English)		
除害劑製造商名稱及地址
Name and Address of Pesticide Manufacturer		
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(s) of Pesticide**	□ 除蟎劑      Acaricide
□ 除藻劑      Algicide
□ 船底防污漆  Antifouling Paint
for Ship Bottom
□ 除真菌劑    Fungicide
□ 除草劑      Herbicide	□ 除蟲劑   Insecticide
□ 殺螺劑   Molluscicide
□ 滅線蟲劑 Nematicide
□ 滅鼠劑   Rodenticide
□ 其他Others                	
除害劑的預期用途**
Intended Use of Pesticide** 
	□ 農業用途 Agricultural Use

□	使用於本地糧食作物 For Use on Local Food Crops(3)
□	除害劑的最高殘餘限量已載於《食物內除害劑殘餘規例》(第132CM章) 附表1－項目編號：
Maximum Residue Limit(s) of the pesticide is/are available in Schedule 1 to the Pesticide Residues in Food Regulation (Cap.132CM) – Item No(s):  

□	屬《食物內除害劑殘餘規例》(第132CM章) 附表2的獲豁免除害劑－項目編號：
An exempted pesticide in Schedule 2 to the Pesticide Residues in Food Regulation (Cap.132CM) – 
Item No: 

□	並非使用於本地糧食作物 Not for Use on Local Food Crops

□ 家居用途 Domestic Use
□ 害蟲防治用途 Pest Control Use
□ 其他 Others                                             	
  ** 請在適當的空格內加上“”號  Please tick as appropriate

(1)如活性成分多於一種，請以符號“／”分隔每種成分的相關資料 (例如：A/B/C)。
  If there is more than one active ingredient, please use the symbol “/ ” to separate the related information for each ingredient (e.g. A/B/C).
(2)有關劑型類別及縮寫，請參閱漁農自然護理署網頁。 
Please refer to AFCD’s website for the types of formulation and abbreviations.

(3)若除害劑擬使用於糧食作物，除非該除害劑屬《食物內除害劑殘餘規例》(第132CM章) 附表2的獲豁免除害劑，否則申請人須提供載列於《食物內除害劑殘餘規例》(第132CM章) 附表1有關該除害劑的最高殘餘限量的資料。
Where the pesticide is intended for use on food crops, the applicant shall provide the Maximum Residue Limit(s) of the pesticide as stipulated in Schedule 1 to the Pesticide Residues in Food Regulation (Cap. 132CM) unless such pesticide is an exempted pesticide stipulated in Schedule 2 to the said Regulation.

#簡寫Abbreviations:	ANSI  	= 美國國家標準協會 American National Standards Institution	
	BSI   	= 英國標準局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	

重要事項 IMPORTANT NOTES
	
��	請確保已遞交“除害劑註冊所需資料”內所需的一切資料和證明文件。
Please ensure that all the necessary information and supporting documents as required on the “Information Requirement for Pesticide Registration” are submitted.
	
��	為了遵守世界貿易組織《與貿易有關的知識產權協議》第39(3)條的規定以及在該條的規限下，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註冊用途後，會：
-	被視作機密資料及保密；
-	只限數位有需要知道該等資料作註冊用途的公務員查閱；及
-	永不用於其他註冊申請，除非獲原資料的供應者書面授權。
In compliance with and subject to the provisions in 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 the registration of a pesticide, are:
-   considered and kept confidential;
-   only viewed by a limited number of Government officers on a need-to-know basis for registration; and
-   never used in other registration applications unless under written authorization from the supplier of the original data.

	
 個人資料收集聲明 PERSONAL INFORMATION COLLECTION STATEMENT
	
��	 你所提供的個人資料將用作申請本署的除害劑註冊的有關事宜。依據《除害劑規例》第4(2)條的規定，
除害劑如經註冊，其註冊申請人的姓名或名稱及地址須記錄在除害劑註冊紀錄冊內，公開讓公眾人士查閱。
The personal data provided by you will be used for purposes relating to the application for pesticide registration in this Department. If the pesticide is registered, the name and address of the person applying for the registration of pesticide would be entered into the Pesticides Register for open inspection pursuant to regulation 4(2) of the Pesticides Regulations.
	
��	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，以供作除害劑註冊申請的統計或調查用途。
Except for the data relating to undisclosed tests 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 agents, contractors or other government departments for statistics or investigation purpose in relation to the application of pesticide registration.
	
��	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 the 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III部：繳費方法
PART III:  PAYMENT METHODS 

申請人可透過下列其中一種方法繳費─
The fee can be settled by one of the following 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)

第 IV部： 申請人聲明
PART IV:  	DECLARATION OF APPLICANT

��	本人現申請給予上述名稱的除害劑註冊，並明白所有除害劑一經註冊，即須按照除害劑規例的規定，附有適當的包裝和標籤。同時，下列與各註冊除害劑有關的資料，均會載列於除害劑註冊紀錄冊，供公眾查閱：
(a)	該除害劑為人所知和在售賣或供應時所採用的化學名稱及通用名稱(如有的話)；
(b)	准以零售方式售賣或供應的除害劑的活性成分濃度及該除害劑的劑型；
(c)	申請將該除害劑註冊的每一人的姓名或名稱及地址；及
(d)	該除害劑的註冊的規限條件(如有的話)。
I hereby apply for registration of the above named pesticide and, in doing so, understand that all pesticides once registered must be properly packed and labelled in accordance with the Pesticides Regulations, and that the following information relating to each registered pesticide is entered into the Pesticides Register which is open for public inspection:
(a)	the chemical name and the common name, if any, by which the pesticide is known and under which it is to be sold or supplied;
(b)	the concentration of the active ingredient(s) and formulation of the pesticide permitted for retail sale or supply;
(c)	the name and address of each person who applied for the registration of the pesticide; and
(d)	the conditions, if any, subject to which the pesticide is registered.

��	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. 
                                                                                        
申請人／公司負責人簽署
Signature of Applicant / Responsible Person for and on behalf of the Company	
公司印鑑Company Chop

申請人／公司負責人姓名
Name of Applicant / Company Responsible Person		
公司名稱
Company Name		
職位Position in Company		
日期Date		

                                                                                                

只供漁農自然護理署填寫For AFCD Official Use Only

Form Received Date		□By Hand □By Post □By Email	
Record No.			
Application Date			
Application Fee	$		
Receipt No.			
File Reference	L/M                        		in AF GR PPR 05/1 	Pt. (        )	
Reg. No. (For inclusion only) 	1P / 2P ___________