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)
除害劑牌照續牌申請書
APPLICATION FOR PESTICIDES LICENCE RENEWAL
本人（負責人） I, (Responsible Person)__________________________________________________________________________
謹代表（公司名稱） On behalf of (Company Name) ______________________________________________________________
公司地址 Company Address __________________________________________________________________________________
電話號碼Phone No. :_______________傳真號碼Fax No. : _______________電郵地址Email Address : ______________________ 

1.	現附上  Enclose the following :

(i)* 續牌費用 Renewal fee ﹕港幣 HK$_________元
 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)
(ii) 有效商業登記證影印本 Photocopy of valid Business Registration Certificate        BRC No.: 
2. 申請更改項目（如有更改始須填寫）Application for variation (complete only if appropriate)
在申請續牌的同時，本人擬一併申請在除害劑牌照上作下述更改*﹕
Concurrent with this renewal request, I also apply for the following change(s) to the Pesticides Licence*:
     負責人              改為    (**先生／女士) 姓：                    名：                                     
   	Responsible person    change to    (**Mr./ Ms.) Surname:                Given name:                                
         	    **香港身份證／護照號碼**H.K. Identity Card / Passport No.__________________________________________
     通訊地址改為 Correspondence address change to                                                           
     #營業地址改為 #Business address change to                                                                
     其他	Other                                                                                        

* 請在適當的空格內加上 “” 號  Please tick as appropriate
** 請刪去不適用的項目  Please delete where not applicable
#《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.

                                                                                                 	                   （負責人簽署）(Signature of Responsible Person)                         （公司印鑑）(Company Chop)  
                                                                                                 
      （職位）   (Position in Company)                                    （日期）  (Date)
申請方法 Method of application:
( I )  如用郵寄方法申請，請把申請書寄往『九龍長沙灣道303號長沙灣政府合署5樓』。 If apply by mail, please send the application to “5/F, Cheung Sha Wan Government Offices, 303 Cheung Sha Wan Road, Kowloon.”
( II ) 如欲親臨辦理，請先到長沙灣政府合署5樓3-4號窗。If apply in person, please go to “counter no. 3-4, 5/F., Cheung Sha Wan Government Offices” first.

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.
��	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.

For official use only  □ ID Checked
                   □ ID Not checked

PAID on _______________  M/R No. _________________

PPRD 12R01B (01/2021)