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)

除害劑許可證延期申請表
(請填寫一式兩份)
APPLICATION FOR PESTICIDES PERMIT EXTENSION
(To be completed in duplicate)

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		
電郵地址
Email Address		電話號碼
Phone No.		傳真號碼
Fax No.		
現申請把除害劑許可證編號
hereby apply for extension of Pesticides Permit No.		延期六個月，由
for six months with effect from		起生效。	

1.	所需文件Documents Required
現夾附下列項目，以供延期之用：
I enclose the following items for the application for extension:	
a.		有效商業登記證影印本
Photocopy of valid Business Registration Certificate	
b.		許可證正本
The original permit	
c.		一份核證報表，列明由 _______________ 至下開日期有關除害劑的所有交易記錄及存貨量
A certified statement of all transaction records and stock balance of the relevant pesticide from _________________ to the date mentioned below	
d.*	延期費用: 港幣 _______________ 元
Extension fee: HK$ _____________

	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) 

2.	申請更改資料 （只在有需要時填寫） Application for Amendment of Particulars (To be completed when needed)
在申請延期的同時，本人擬一併更改除害劑許可證中的下述資料*:
In parallel with this extension application, I would also like to request for the following amendment(s) to the particulars on the Pesticides Permit*: 	
	
	負責人
Responsible Person	改為
changed to	**先生／女士
**Mr. / Ms.	電郵地址
Email Address			
		**香港身分證／護照號碼
**H.K. ID Card / Passport No.		職位
Position in Company			
		電話號碼
Phone No.			傳真號碼
Fax No.		
	
	除害劑處理人Pesticide Handler	改為
changed to	**先生／女士
**Mr. / Ms.	電郵地址
Email Address			
		**香港身分證／護照號碼
**H.K. ID Card / Passport No.		職位
Position in Company			
		電話號碼
Phone No.			傳真號碼
Fax No.			
	# 地址
# Address	改為
changed to			
	其他
Other				

Remarks	*  請在適當的空格內加上“”號	
	Please tick as appropriate	
	   請附上有關文件	
	Please provide the relevant document(s)	
	** 請刪去不適用的項目	
	Please delete where not applicable	
	# 《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。其中的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) 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.	

3.	聲明 Declaration
在申請除害劑許可證延期時，本人明白如申請獲批准，本人須對該許可證負上責任，並須遵守許可證載列的所有條件。
In applying for extension of the 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.	
			
(負責人簽署)
(Signature of Responsible Person)		(公司印鑑)
(Company Chop)	
			
(職位) 
(Position in Company)		(日期) 
(Date)	

查詢請電 
Enquiry Telephone Number	只供漁農自然護理署職員填寫	For AFCD Official Use Only	Collection code: 43	
2150 7008	Ref. No.: PPA _______________	Received on _______________	M/R No. _____________	

個人資料收集聲明 PERSONAL INFORMATION COLLECTION STATEMENT	
��	你提供的資料將用於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 a 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 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 agent, contractor or other government departments for statistics or investigation purposes in relation to the application for a 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 in writing 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.