2017年中醫執業資格試申請書(適用於非表列中醫人士) LE1

Transcription

1 表格 FORM:LE1 香港中醫藥管理委員會 The Chinese Medicine Council of Hong Kong 2017 年中醫執業資格試申請書 ( 適用於非表列中醫人士 ) Application Form for Taking the 2017 Chinese Medicine Practitioners Licensing Examination (For Applicants other than Listed Chinese Medicine Practitioners) 香港法例第 549 章 中醫藥條例 Chinese Medicine Ordinance (Cap. 549) 申請人必須把已填妥的申請書, 於 2016 年 9 月 19 日 ( 星期一 ) 至 2016 年 10 月 31 日 ( 星期一 ) 內 ( 包括首尾兩日 ), 連同報名表及申請費港幣 1,340 元, 以掛號郵遞方式或親身送達香港中醫藥管理委員會秘 1 書處 逾期申請, 恕不接受 申請人亦可以繳費靈繳付申請費 如以掛號郵遞方式遞交申請書及報名表, 則以郵戳日期為準 Applicants must submit the application form together with the enrolment form and the application fee of Hong Kong Dollars 1,340 to the Secretariat of the Chinese Medicine Council of Hong Kong by registered post or in person from 19 September 2016 (Monday) to 31 October 2016 (Monday) (inclusive). Late applications will not be accepted. Applicants may pay the application fee by using Payment by Phone Service (PPS) 1. For application forms and enrolment forms submitted by post, the post mark will be taken as the submission date. 請沿虛線剪下及保留 申請書填寫指引 Please retain the Guidance Notes attached to this application form by cutting along the dotted line. 附註 Note 1: 有關繳費靈的繳費詳情, 請參閱考生手冊 1: Regarding the payment by using PPS, please refer to the Candidates Handbook for details. 2: 此申請書只適用於根據 中醫藥條例 第 61 條第 (1)(a) 款申請參加中醫執業資格試的非表列中醫人士 2: This application form is only for applicants who are not listed Chinese medicine practitioners applying to take the Licensing Examination under Section 61(1)(a) of the Chinese Medicine Ordinance. 3: 中醫執業資格試只備有中文試卷 3: The Licensing Examination papers are printed in Chinese only.

2 中醫執業資格試申請書填寫指引 表格 :LE1 填寫申請書前, 請先閱讀以下指引 申請參加中醫執業資格試 1. 申請人必須符合考生手冊第一部分 考試制度 第一項 參加資格 內所訂明的資格, 才會被批准參加中醫執業資格試 2. 申請人必須填寫中醫執業資格試申請書 ( 表格 LE1) 及報名表 ( 表格 LE1A), 向香港中醫藥管理委員會中醫組 ( 下稱 中醫組 ) 申請參加中醫執業資格試及繳付訂明的申請費 3. 請於 2016 年 9 月 19 日 ( 星期一 ) 至 2016 年 10 月 31 日 ( 星期一 ) 內 ( 包括首尾兩日 ), 把已填妥的中醫執業資格試申請書, 連同報名表及申請費港幣 1,340 元, 以掛號郵遞方式或親身送達香港中醫藥管理委員會秘書處 ( 下稱 秘書處 ) 逾期申請, 恕不接受 申請人亦可以繳費靈 1 繳付申請費 如以掛號郵遞方式遞交申請書及報名表, 則以郵戳日期為準 4. 申請人將於 2017 年 5 月或之前獲通知參加中醫執業資格試的申請結果 5. 中醫執業資格試包括第 I 部分筆試及第 II 部分臨床考試兩個部分 第 I 部分筆試暫定於 2017 年 6 月舉行 中醫組將於 2017 年 4 月上旬, 在香港中醫藥管理委員會 ( 下稱 管委會 ) 網頁公佈及以書面通知考生舉行筆試的確實日期 香港考試及評核局 ( 下稱 考評局 ) 會於 2017 年 5 月下旬將印有筆試日期 時間及地點的准考證及考生須知等資料郵寄給考生 6. 第 II 部分臨床考試暫定於 2017 年 8 月舉行 考生必須於中醫執業資格試第 I 部分筆試取得合格成績, 才有資格報名參加第 II 部分臨床考試 筆試結果將於 2017 年 7 月上旬以書面通知考生, 在筆試 ( 包括卷一及卷二 ) 取得合格的考生, 可報名參加臨床考試 在確定臨床考試人數後, 考評局將以電腦抽籤的方式編排考試日期及時間, 然後於 2017 年 7 月下旬將印有臨床考試日期 時間及地點的准考證及考生須知等資料郵寄給考生 7. 中醫組保留更改考試日期的權利 申請費及考試費 8. 申請費及考試費如下 : 申請費 : $1,340 考試費 : 第 I 部分 筆試 : $2,340 第 II 部分 臨床考試 : $3,550 ( 考試費在申請獲批准後, 才須繳付 ) ( 註 : 費用如有變更, 將於管委會網頁公布 ) 1: 有關繳費靈的繳費詳情, 請參閱考生手冊 F1

3 9. 申請人在遞交申請書及報名表時, 須附有一張已填寫申請費港幣 1,340 元的劃線支票 銀行本票或匯票 支票 銀行本票或匯票的收款人須寫上 香港特別行政區政府 或 The Government of the Hong Kong Special Administrative Region 或 The Government of the HKSAR, 並在背面寫上申請人的姓名 申請人亦可以繳費靈 1 繳付申請費 切勿郵寄現金 10. 申請獲批准後, 考生會獲通知繳交筆試考試費 臨床考試費則在考生取得筆試合格後, 才須繳交 11. 在任何情況下, 申請人已繳付的申請費及考試費均不會獲得發還或轉作其他用途 12. 任何人士如重考中醫執業資格試的任何部分, 均須繳交當時所訂明的申請費及考試費 一般事項 13. 請用黑色墨水筆或原子筆填寫申請書及報名表 14. 申請人須填妥申請書及報名表各項 ( 包括中英文地址 ), 並提供正確資料 15. 請以正楷中文或英文填寫申請書及報名表 16. 請附上三幀不大於 50x60 毫米, 亦不少於 40x50 毫米的申請人近照 ( 在提交申請前 6 個月內拍攝的照片 ) 其中一幀照片須貼於申請書上, 另一幀貼於報名表上, 第三幀相片背面須寫上申請人姓名 17. 申請人如未能提供所需的一切文件及資料, 其申請將不獲受理 18. 申請人應保留一份填妥的申請書及報名表副本, 以備參考 19. 如申請書空位不敷填寫, 請另頁填寫, 並在申請書有關部分註明 申請人須在附頁上寫上其姓名及簽署, 然後將附頁釘附在申請書內 住址及通訊地址 20. 請提供中英文住址及通訊地址 21. 所有關於參加中醫執業資格試的通知書 准考證及考生須知等文件均會寄往申請人的通訊地址 申請人的住址 通訊地址 電話號碼 傳真號碼或電郵地址如有變更, 必須立即通知秘書處 ( 電話號碼 : , 傳真號碼 : , 電郵地址 :exam@cmchk.org.hk) 中醫學歷 22. 請在申請書 B 部第 1 項 學校名稱 欄上, 填上適當的編號, F2

4 請參閱考生手冊附表一的學校編號 23. 請在申請書 B 部第 1 項 課程名稱 欄上, 填寫修讀課程的全名, 所填寫的課程名稱必須與學歷證明文件所列載的資料一致 24. 如申請人在香港以外的機構取得有關的中醫學位學歷, 須提供有關院校的詳情, 包括院校地址 聯絡電話及傳真號碼等 如有關院校無法被聯絡以核實申請人的學歷, 申請將不會獲接納 25. 請在申請書 B 部第 3 項 醫院或診所名稱 欄上, 填寫申請人在修讀中醫學位課程期間, 全部的畢業實習醫院或診所名稱, 所提供的資料必須與畢業實習證明文件所列載的資料一致 26. 請在申請書 B 部第 4 項 頒發機構 欄上填寫頒發有關中醫學位學歷證書的機構, 以及在 國家 / 地域 欄上填寫機構所屬的國家 省份或地區 27. 請在申請書 B 部第 4 項 學歷 欄上, 填寫獲頒發的中醫學位學歷, 所填寫的學歷資格必須與學歷證明文件所列載的資料一致 遞交申請書及報名表 28. 申請人必須把填妥的中醫執業資格試申請書及報名表, 連同申請費 身份證明文件及有關學歷證明文件的公證影印副本, 在 2016 年 9 月 19 日 ( 星期一 ) 至 2016 年 10 月 31 日 ( 星期一 ) 期間 ( 包括首尾兩日 ), 以掛號郵寄方式送達秘書處 ( 如截止日期當天因天文台發出八號或以上的熱帶氣旋警告或黑色暴雨警告, 截止日期將順延至下一個工作日 ) 切勿郵寄現金 逾期申請, 恕不接受 29. 申請人亦可在中醫組指定的申請期內親身前往秘書處遞交申請 在這情況下, 申請人可提供證明文件的正本以供秘書處職員核對, 而所遞交的證明文件的副本便無須經過公證 30. 秘書處在收到申請書及報名表後, 會為申請人編配一個申請編號 這個編號將在申請人仍為中醫執業資格試的考生及合乎資格參加考試的期間內維持有效 31. 考評局將在考試前把准考證及考生須知郵寄給考生 如考生在考試日期前一星期仍未收到該等文件, 請致電考評局查詢 32. 考生必須在第 I 部分筆試 ( 包括卷一及卷二 ) 取得合格成績, 才有資格報名參加第 II 部分臨床考試 筆試合格成績可保留 5 年, 如考生於 5 年內未能通過臨床考試, 便須重考及通過筆試 ( 包括卷一及卷二 ), 才有資格參加臨床考試 33. 由 2007 年起計, 首次參加 * 筆試的人士必須同時報考卷一及卷二 若考生於 2007 年或以後於筆試其中一卷取得合格成績, 便可保留該卷的合格成績 3 年及選擇補考另一 F3

5 卷, 但考生必須於 3 年內補考 * 另一卷並取得合格, 否則, 便須重考筆試 ( 包括卷一及卷二 ) 除補考外, 所有參加筆試的人士必須同時報考卷一及卷二 如考生於筆試報考兩卷, 可以兩卷或單卷總分計算合格成績 凡於同一筆試以兩卷總分計算取得合格, 或於 2007 年或以後於 3 年內分別取得兩卷合格, 即通過筆試 如申請人申請重考 / 補考筆試, 只須填妥報名表 ( 表格 LE1A), 並清楚註明申請重考 / 補考的考試部分 申請重考 / 補考中醫執業資格試的任何部分, 均須繳交訂明的申請費及考試費 申請補考筆試其中一卷, 亦須繳交全部筆試費用 (* 此項規定內有關 首次參加 或 補考 筆試的定義並不計算考生於 2007 年前參加筆試的次數及成績, 即所有於 2007 年參加筆試的人士, 均視作首次參加筆試, 而只有於 2007 年或以後通過筆試其中一卷的考生, 方可於 3 年內補考另一卷 ) 34. 於截止日期後收到及未有繳付訂明費用的申請表及報名表, 均不會被接納及處理 認收信 35. 申請書及報名表必須於 2016 年 9 月 19 日 ( 星期一 ) 至 2016 年 10 月 31 日 ( 星期一 ) 期間送達秘書處 ( 如截止日期當天因天文台發出八號或以上的熱帶氣旋警告或黑色暴雨警告, 截止日期將順延至下一個工作日 ) 秘書處在收到申請書及報名表後, 會發出註有申請編號的認收信 如申請人在遞交申請書及報名表後兩星期仍未收到認收信, 請立即致電 與秘書處聯絡 為了避免郵遞延誤, 申請人須在認收信表格上清楚填寫姓名和地址 只有已獲秘書處認收的申請書及報名表, 才會獲得處理 面見 36. 如有需要, 秘書處會約見申請人核實其證明文件 提供虛假資料 37. 根據 中醫藥條例 第 107 條的規定, 任何人藉作出或交出, 或藉導致作出或導致交出, 口頭或書面的任何虛假或有欺詐成分的申述或聲明而欺詐地促致或企圖促致其本人或任何其他人, 獲得註冊為註冊中醫, 即屬犯罪, 一經循公訴程序定罪, 可處監禁 3 年 38. 根據香港法例第 200 章 刑事罪行條例 第 36(a) 條的規定, 凡經宣誓而作失實聲明者, 均屬違法 違例者可被判入獄 2 年及罰款 聲明 39. 申請人必須作出宣誓, 確認申請書 ( 表格 LE1) 內所填報的各項詳情及夾附的所有文件及資料, 就其所知道的, 均屬真實及正確 申請人可於辦公時間到秘書處辦理宣誓 境外人士可在其國家的公證處宣誓 F4

6 防止賄賂 40. 根據香港法例第 201 章 防止賄賂條例 的規定, 向任何擔當與中醫執業資格試及中醫註冊有關事宜的人士提供任何利益 ( 金錢或禮物 ), 以影響其申請之有關處理, 均屬違法, 可處監禁 7 年及罰款港幣 500,000 元 收集個人資料的目的 41. 申請人向中醫組提供的個人資料, 將會作為審核申請和安排考試的用途 申請人提供其個人資料, 出於自願 可是, 如果申請人不提供充分資料, 中醫組可能無法處理其申請 個人資料的轉介 42. 申請人所提供的個人資料, 主要由管委會內部使用, 但亦可能因以上第 41 段所列目的, 向考評局 ( 作為安排考試之用 ) 及其他政府部門 中介機構或行政管理機構披露 除此之外, 申請人的個人資料祗會在其本人同意下, 又或是在 個人資料 ( 私隱 ) 條例 所容許下, 才會向其他人士或機構披露 查閱及修改個人資料 43. 根據 個人資料 ( 私隱 ) 條例 第 18 條及 22 條以及其附表 1 第 6 原則所述, 申請人有權查閱及修正個人資料 查閱資料時, 申請人可能需要繳交費用 申請人的資料如有任何更改, 須盡快以書面寄交秘書處 來函或查詢 44. 申請書 報名表及所有來函, 應送交秘書處, 信封上請註明 中醫執業資格試 秘書處的地址和聯絡方法如下 : 地址 : 香港灣仔 皇后大道東 213 號 胡忠大廈 22 樓 2201 室 香港中醫藥管理委員會秘書處 傳真號碼 : (852) 電話號碼 : (852) 互聯網網址 電郵地址 辦公時間 : : exam@cmchk.org.hk : 星期一至五上午九時至下午五時三十分 ( 星期六 日及公眾假期休息 ) F5

7 FORM: LE1 Guidance Notes on Completing the Application Form for Taking the Chinese Medicine Practitioners Licensing Examination Please read the following notes carefully before completing the application form. Application for taking the Chinese Medicine Practitioners Licensing Examination 1. To be eligible for taking the Chinese Medicine Practitioners Licensing Examination (the Licensing Examination), applicants should satisfy the requirements as stipulated in Section (1) Eligibility for Examination under Part(1) The Examination System of the Candidates Handbook. 2. In applying to sit the Licensing Examination, applicants must complete the application form (FORM : LE1) and the enrolment form (FORM : LE1A) and pay the prescribed application fee. 3. Applicants must submit the application form, together with the enrolment form and application fee of Hong Kong Dollars 1,340, to the Secretariat of the Chinese Medicine Council of Hong Kong (the Secretariat) by registered post or in person from 19 September 2016 (Monday) to 31 October 2016 (Monday) (inclusive). Late applications will not be accepted. Applicants may pay the application fee by using Payment by Phone Service (PPS) 1. For application forms and enrolment forms submitted by post, the post mark will be taken as the submission date. 4. Applicants will be informed of the results of their applications in or before May The Licensing Examination consists of two parts, viz. Part I Written Examination and Part II Clinical Examination. The Part I Written Examination will be held in June 2017 (tentative). The Practitioners Board will announce the dates of the Part I Written Examination on the website of the Chinese Medicine Council of Hong Kong (the Council) and notify candidates by mail in early April The Hong Kong Examinations and Assessment Authority (HKEAA) will mail Admission Forms printed with the dates, time and location of the Written 1: Regarding the payment by using PPS, please refer to the Candidates Handbook for details. F6

8 Examination, and Instructions to Candidates to the candidates around late May The Part II Clinical Examination will be held in August 2017 (tentative). Only candidates who pass the Part I Written Examination are eligible for undertaking the Part II Clinical Examination. Candidates will be notified of the results of the Part I Written Examination in early July Candidates who pass the Written Examination (including Paper 1 and Paper 2) may then apply for the Clinical Examination. The date and time of the Clinical Examination will be assigned on a random basis by computer after the number of candidates is confirmed. The HKEAA will mail Admission Forms printed with the date, time and location of the Clinical Examination, and Instructions to Candidates to the candidates around late July The Practitioners Board reserves the right to change the dates of the examination. Application and examination fees 8. The application and examination fees are as follows: Application fee: $1,340 Examination fees: Part I Written Examination: $2,340 Part II Clinical Examination: $3,550 (Examination fees should be paid after the application for taking the Licensing Examination is approved.) (Revision of the application and examination fees, if any, will be announced on the website of the Council.) 9. A crossed cheque, bank draft or money order in the amount of the application fee of Hong Kong Dollars 1,340 payable to 香港特別行政區政府 or The Government of the Hong Kong Special Administrative Region or The Government of the HKSAR and bearing the applicant s name on its back should be enclosed with the application form. Applicants may pay the application fee by using Payment by Phone Service (PPS) 1. Cash should not be enclosed with the enrolment. 10. Successful applicants will be asked to pay the examination fee for Part I Written Examination when their applications for taking the Licensing Examination are approved. The examination fee for Part II Clinical F7

9 Examination should be paid after passing the Written Examination. 11. Under no circumstances will the application fee and the examination fee be refunded or transferred for other uses. 12. Applicants applying to re-sit any part of the Licensing Examination have to pay both the application fee and the examination fees as prescribed. General notes 13. Please complete the application form and the enrolment form in black ink. 14. Applicants should ensure that all parts of the application form and the enrolment form are completed (including the address in both Chinese and English) and that the information is accurate. 15. Please complete the application form and the enrolment form in block letters in either Chinese or English. 16. Three recent photographs not larger than 50 x 60 mm and not smaller than 40 x 50 mm taken within 6 months before submission of the application form should be enclosed. Two of them should be affixed to the application form and the enrolment form respectively. Please write the applicant s name on the back of the third photograph. 17. An application will not be considered if the required documents and information is not provided. 18. Applicants should keep a photocopy of the completed application form and enrolment form for record. 19. If there is insufficient space on the application form, please use separate sheets and indicate in the relevant part. Please write the applicant s name and sign on the separate sheets, and attach them to the application form. Residential and correspondence addresses 20. Please provide the residential and correspondence addresses in both Chinese and English. 21. All notifications, letters, Admission Forms and Instructions to Candidates will be sent to the correspondence address. If there is a change in the residential address, correspondence address, telephone number, fax number or address, please notify the Secretariat immediately (telephone number: , fax number: , address: exam@cmchk.org.hk). F8

10 Academic qualification in Chinese Medicine 22. Please write the school code in the Name of Schools column of item 1, section B of the application form according to Table 1 of the Candidates Handbook. 23. Please write the full title of the course in the Course Title column of item 1, section B of the application form. The course title as printed on the academic certifications should be used. 24. If an applicant s degree in Chinese medicine was awarded by an institute outside Hong Kong, please provide the address, telephone number, and fax number of the institute. If the institute cannot be contacted to verify the applicant s academic qualifications, the application will not be accepted. 25. Please write the name of all the hospitals or clinics where clinical training is received in the Name of Hospital or Clinic column of item 3, section B of the application form. The names of hospitals or clinics as printed on the certification of clinical training should be used. 26. Please write the name of the institute awarding the degree in Chinese medicine in the Issuing Authority column of item 4, section B of the application form, and write the country, province or region where the institute is located in the Country/ Region column. 27. Please write the title of an applicant s degree in Chinese medicine in the Academic Qualification column of item 4, section B of the application form. The title as printed on the academic certification should be used. Submission of application and enrolment forms 28. Applicants must submit the application form and the enrolment form, together with the application fee and the copies of documents showing the applicant s identification and academic qualifications, to the Secretariat by registered post from 19 September 2016 (Monday) to 31 October 2016 (Monday) (inclusive) (If Tropical Cyclone Warning Signal No. 8 or above or a Black Rainstorm Warning Signal is issued by the Hong Kong Observatory on the deadline of the application period, the closing date for application will be postponed to the following working day.). All copies of identification documents and academic certificates must be certified by a notary public. Cash should not be enclosed with the application. Late applications will not be accepted. 29. Applicants may submit the application in person within the application period and produce the original documents to the Secretariat staff for verification, without submitting copies from a notary public. F9

11 30. Upon receipt of the application form and the enrolment form, an applicant will be allocated an application number which will remain valid during the period when he is eligible to sit the Licensing Examination. 31. The HKEAA will mail the Admission Form and the Instructions to Candidates to the candidates before the examination. Any candidate who does not receive the documents one week before the examination should contact the HKEAA immediately. 32. Candidates must obtain a pass in Part I Written Examination (both Paper 1 and Paper 2) before they are eligible for taking Part II Clinical Examination. The result of a pass in the Written Examination may be retained for 5 years. If a candidate cannot pass the Clinical Examination within 5 years, he must re-sit and pass the Written Examination (both Paper 1 and Paper 2) before he is eligible for undertaking the Clinical Examination again. 33. An applicant who applies to take the Written Examination for the first time (counting from 2007)* must enrol in both Paper 1 and Paper 2. A candidate who passes either of the two papers in 2007 or thereafter will be allowed to retain the pass result for 3 years and he may choose to make up the other paper. However, he must pass the other paper within 3 years, otherwise he must re-sit the Written Examination (both Paper 1 and Paper 2). Other than making up, an applicant must enrol in both Paper 1 and Paper 2. If a candidate enrols in both papers, the passing mark will be determined on the basis of the total score of the two papers or either paper. A candidate who passes both papers in a single examination, or passes both papers within a period of 3 years after 2007 would be regarded as having passed the Written Examination. If an applicant applies to re-sit or make up the Written Examination, he should complete the enrolment form (FORM:LE1A) only and state clearly the part to be taken. An applicant applying to re-sit should pay the prescribed application and examination fees. An applicant applying to make up either paper of the Written Examination has to pay the prescribed fee for the Written Examination. (*The definitions of taking the Written Examination for the first time and making up the Written Examination do not cover the attempts and the results obtained before All candidates undertaking the Written Examination in 2007 will be regarded as taking the Written Examination for the first time. Only those candidates who pass either of the two papers of the Written Examination in or after 2007 are eligible to make up the other paper.) 34. The application forms or the enrolment forms received after the close of the application period and applications and enrolments enclosing no fee payment will not be accepted and processed. F10

12 Acknowledgement of application and enrolment forms 35. The application forms and the enrolment forms must reach the Secretariat from 19 September 2016 (Monday) to 31 October 2016 (Monday) (inclusive) (If Tropical Cyclone Warning Signal No. 8 or above or a Black Rainstorm Warning Signal is issued by the Hong Kong Observatory on the deadline of the application period, the closing date for application will be postponed to the following working day.). The Secretariat will then issue acknowledgement letters and inform the applicants of their application numbers. Any applicant who does not receive the acknowledgement two weeks after submission of the application form and the enrolment form should contact the Secretariat at immediately. Please print the applicant s name and address clearly on the acknowledgement forms to avoid errors in mailing. Only acknowledged applications will be processed. Interview 36. Where necessary, applicants may be required by the Secretariat to attend an interview to verify the authenticity of the supporting documents. Provision of false information 37. In accordance with Section 107 of the Chinese Medicine Ordinance, any person who fraudulently procures or attempts to procure himself or any other person to be registered as a registered Chinese medicine practitioner, by making or producing, or causing to be made or produced, any false or fraudulent representations or declaration, either oral or in writing, commits an offence and is liable on conviction upon indictment to imprisonment for 3 years. 38. In accordance with Section 36(a) of the Crimes Ordinance (Cap. 200 of the Laws of Hong Kong), any person who gives a false statement in a statutory declaration commits an offence. The penalty is imprisonment for 2 years and a fine. Declaration 39. Applicants are required to take an oath to confirm that the information provided in the application form (FORM:LE1) and all the accompanying documents are, to the best of his knowledge and belief, true and correct. Declaration may be made at the Secretariat during office hours. Applicants living outside Hong Kong may make the declaration before a notary public of their own country. Prevention of bribery 40. In accordance with the Prevention of Bribery Ordinance (Cap. 201 of the Laws of Hong Kong), any person who offers any advantage (money or gift) to any F11

13 persons involved in the Licensing Examination and registration of Chinese medicine practitioners to influence the processing of his application, commits an offence and is liable to imprisonment for 7 years and a fine of Hong Kong Dollars 500,000. Purpose of collecting personal data 41. The personal data given to the Practitioners Board by the applicants will be used for processing their applications for taking the Licensing Examination and necessary arrangements. The provision of personal data is voluntary. However, if an applicant does not provide sufficient information, the Practitioners Board may not be able to process his application. Transfer of personal data 42. The personal data provided by an applicant are mainly for use of the Council, but they may be disclosed to the HKEAA for arranging the examination and other Government bureaux / departments, agencies or authorities for the purposes mentioned in paragraph 41 above. Apart from this, the applicant s personal data will only be disclosed to other persons or organizations if he has given consent to such disclosure or such disclosure is allowed under the Personal Data (Privacy) Ordinance. Access to personal data 43. Applicants have the right of access and correction with respect to their personal data in accordance with Sections 18 and 22 and Principle 6 of Schedule 1 of the Personal Data (Privacy) Ordinance. A fee may be imposed for complying with a data access request. If there is a change in the personal data, the applicants should notify the Secretariat as early as practicable. F12

14 Correspondence or enquiries 44. Please send the application forms, the enrolment forms and all correspondences to the Secretariat s address below, and state Licensing Examination on the envelope: Address : The Secretariat of the Chinese Medicine Council of Hong Kong Rm 2201, 22/F, Wu Chung House, 213 Queen s Road East, Wanchai, Hong Kong. Fax No. : (852) Telephone No. : (852) Website : address : exam@cmchk.org.hk Office hours : 9:00a.m. - 5:30p.m. (Monday to Friday) (Closed on Saturdays, Sundays and public holidays) F13

15 表格 FORM:LE1 申請編號 : Application No.: 香港中醫藥管理委員會 The Chinese Medicine Council of Hong Kong 2017 年中醫執業資格試申請書 ( 適用於非表列中醫人士 ) Application Form for Taking the 2017 Chinese Medicine Practitioners Licensing Examination (For Applicants other than Listed Chinese Medicine Practitioners) 香港法例第 549 章 中醫藥條例 Chinese Medicine Ordinance (Cap. 549) 此申請書只適用於根據 中醫藥條例 第 61 條第 (1)(a) 款申請參加中醫執業資格試的非表列中醫人士 This application form is only for applicants who are not listed Chinese medicine practitioners applying to take the Licensing Examination under Section 61(1)(a) of the Chinese Medicine Ordinance. A 部個人資料 ( 請以正楷書寫 ) Section A Personal Particulars (Please write in BLOCK LETTERS) 中文姓名 先生 小姐 女士 Name in Chinese Mr. Miss Ms. 英文姓名 Name in English 出生日期 Date of Birth 出生地點 Place of Birth 姓氏 (Surname ) 香港身份證號碼 Hong Kong Identity Card No. - ( 如適用者 ) (If applicable) 護照 / 身份證明文件號碼 Passport/ Identification Document No. ( 本欄供沒有香港身份證的申請人填寫 ) (for applicants without Hong Kong Identity Card ) 名 (Other Name) 注意 : 姓名應以香港身份證 / 護照 / 身份證明文件上所登記為準 NOTE : Your name must be the same as that appearing on your Hong Kong Identity Card/Passport/Identification Document. 日 Day 月 Month 年 Year 護照 / 身份證明文件種類 Passport/ Identification Document Type ( 本欄供沒有香港身份證的申請人填寫 ) (for applicants without Hong Kong Identity Card ) 日間聯絡電話 / 流動電話號碼 Day Time Contact Telephone No. - - 住宅電話號碼 Residential Telephone No. - - 傳真號碼 Fax No. - - 國家號碼 Country Code 電郵地址 Address 注意 : 請附交身份證明文件副本 N.B. : Please attach a copy of the proof of identity. 區域號碼 Area Code 簽發機關 Issuing Authority 請在適當方格內加上 號 Please in the appropriate box. LE1 1

16 ( 如適用, 請提供中文及英文地址 ) (If applicable, please provide the address in both Chinese and English.) 中文住址 Residential Address in Chinese 室 (Flat) 樓 (Floor) 座 (Block) 大廈 (Building) / 屋邨 (Housing Estate) 街道 (Street) 地區 (District) 城市 (City) / 國家 (Country) 郵政編碼 (Postal Code / Zip Code) 英文住址 Residential Address in English 室 (Flat) / 樓 (Floor) / 座 (Block) 大廈 (Building) 屋邨 (Housing Estate) 街道 (Street) 地區 (District) 城市 (City) / 國家 (Country) 郵政編碼 (Postal Code / Zip Code) ( 如通訊地址與以上地址不同, 請填寫以下部分 ) (If the correspondence address is different from the above address, please fill in the following parts.) 中文通訊地址 Correspondence Address 室 (Flat) 樓 (Floor) 座 (Block) in Chinese 大廈 (Building) / 屋邨 (Housing Estate) 街道 (Street) 地區 (District) 城市 (City) / 國家 (Country) 郵政編碼 (Postal Code / Zip Code) 英文通訊地址 Correspondence Address in English 室 (Flat) / 樓 (Floor) / 座 (Block) 大廈 (Building) 屋邨 (Housing Estate) 街道 (Street) 地區 ( District) 城市 (City) / 國家 (Country) 郵政編碼 (Postal Code / Zip Code) LE1 2

17 B 部中醫學歷 Section B Academic Qualification in Chinese Medicine 請注意 : 只有已圓滿地完成列載於考生手冊附表一的院校所舉辦的中醫組認可的課程, 才符合資格參加中醫執業資格試 Note: Only those applicants who have satisfactorily completed the courses recognized by the Practitioners Board as listed in Table 1 of the Candidates Handbook, are eligible to undertake the Chinese Medicine Practitioners Licensing Examination. 1. 曾接受不少於 5 年的中醫執業訓練本科學位課程 UNDERGRADUATE DEGREE COURSE OF TRAINING IN CHINESE MEDICINE PRACTICE OF NOT LESS THAN 5 YEARS 院校名稱上課方式 ( 請參照 2017 年中醫執業就讀日期請在方格內用 號註明是否在資格試考生手冊 課程名稱 ( 日 / 月 / 年 ) 校全時間制 或遙距授課 ( 包括函附表一的院校編號 ) 課程年期就讀班級 Course Title Period Attended 授或網授或自學考試課程 ) 等 Name of Schools Years of Class Attended / ( 例 : 中醫學專業 ) (Day/Month/Year) Mode of Attendance (Please fill in the code as listed at the Course Attending (e.g.: Chinese medicine) 由至 Please in the box to indicate if it is full- Table 1 of the Candidates time on campus, or distance learning Handbook of the 2017 From To (including correspondence or web-based or Chinese Medicine Practitioners self-learning programme), etc Licensing Examination ) 在校全時間制是否 Full-time on Campus Yes No 遙距授課是否 Distance Learning Yes No 其他 Others 在校全時間制是否 Full-time on Campus Yes No 遙距授課是否 Distance Learning Yes No 其他 Others 在校全時間制是否 Full-time on Campus Yes No 遙距授課是否 Distance Learning Yes No 其他 Others 2. 如果你於香港以外的中醫藥院校畢業, 請填寫以下部分 : IF YOU GRADUATED FROM A CHINESE MEDICINE SCHOOL(S) OUTSIDE HONG KONG, PLEASE FILL IN THE FOLLOWINGS: 電話號碼傳真號碼地址院校名稱 ( 請寫上國家號碼 / ( 請寫上國家號碼 / ( 請寫上郵政編碼 ) Name of School 地區號碼 ) 地區號碼 ) Address (with postal code / zip code) Telephone Number Fax Number (with country code / area code) (with country code / area code) 請在適當方格內加上 號 Please in the appropriate box. LE1 3

18 3. 中醫學位課程畢業實習 CLINICAL TRAINING OF THE DEGREE COURSE IN CHINESE MEDICINE 請列出在接受中醫執業訓練本科學位課程的畢業實習期間所獲得的臨床實習訓練 List below any clinical training received during your study of the undergraduate degree course of training in Chinese medicine practice 醫院或診所名稱 Name of Hospital or Clinic 地點 Place 實習日期 ( 日 / 月 / 年 ) Period of Clinical Training Attended (Day/Month/Year) 由至 From To 請註明是否已夾附由院校發出的畢業實習證明文件副本 Please indicate if copies of the documentary evidence of the clinical training issued by the schools are attached 是 Yes 否 No 是 Yes 否 No 是 Yes 否 No 是 Yes 否 No 4. 中醫學位學歷 ( 請夾附所有成績單及學歷證明文件副本 ) ACADEMIC ATTAINMENT IN CHINESE MEDICINE (PLEASE ATTACH COPIES OF ALL TRANSCRIPTS AND ACADEMIC QUALIFICATIONS) 請提供所獲中醫學位學歷詳情 Please provide details of the degree in Chinese medicine obtained 頒發機構 Issuing Authority 國家 / 地域 Country/Region 頒發日期 ( 日 / 月 / 年 ) Date Issued (Day/Month/Year) 學歷 Academic Qualification ( 例 : 中醫學學士學位 ) (e.g.: Degree of Chinese Medicine) 請註明是否已夾附所需成績單 ( 包括臨床訓練 ) 及學歷證明文件副本 Please indicate if copies of transcripts (including clinical training) and documentary evidence of academic qualifications are attached 畢業證書 Graduate Certificate 成績單 Full Transcript 畢業證書 Graduate Certificate 成績單 Full Transcript 畢業證書 Graduate Certificate 成績單 Full Transcript 是 Yes 否 No 是 Yes 否 No 是 Yes 否 No 是 Yes 否 No 是 Yes 否 No 是 Yes 否 No 請在適當方格內加上 號 Please in the appropriate box. LE1 4

19 * 注意 : 必須連同申請書遞交有關學歷證明文件副本, 包括畢業證書 學位證書 成績單 ( 如成績單沒有顯示合格分數, 請另附院校說明 ) 畢業實習證明 ( 須顯示學生姓名 課程名稱 畢業院校 實習醫院名稱 各實習科目名稱及實習日期 周數 實習成績及合格分數等 ) 及修讀地點證明 ( 須顯示學生姓名 課程名稱 就讀院校 修讀年期及各科詳細的修讀地點 ( 如教學大樓名稱及地址 ) 等 ) 院校發出的證明文件, 每頁必須由院長 教務處處長或獲授權人員簽署及蓋章 假如不能遞交所需的學歷證明文件副本, 請另用白紙述明理由, 與申請書一併附交 中醫組只會在非常特殊情況下, 才考慮並無學歷證明文件副本夾附的申請書 * N.B. : Please submit the application with attached copies of documentary evidence of academic qualifications, including Graduation and Degree certificates, Transcript of Academic Record (with passing grade), Clinical Training Record (showing your name, course title, school name, name of hospital or clinic, all subject names, period, no. of study weeks of each subject, results, and passing mark etc) and Record of Place of Study (showing your name, course title, school name, duration and details of place of study of each subject (with building name and address) etc). Documents issued by the school should be signed by the dean, the director of academic affairs office or an authorized officer of the school. The official chop of the school should also be provided. If you are unable to submit copies of the required documentary evidence of academic qualifications, please give your reasons in writing on additional sheet(s) and attach it/them to your application. Applications without copies of academic documentary evidence will be considered only under very exceptional circumstances. C 部其他證明文件清單 Section C List of Other Documentary Evidence 除 B 部已列出的學歷證明文件外, 請於以下表內列出連同此申請書遞交的其他證明文件副本 OTHER THAN THE ACADEMIC DOCUMENTARY EVIDENCE LISTED IN PART B, PLEASE LIST IN THE TABLE BELOW ALL THE DOCUMENTS THAT ARE ATTACHED TO YOUR APPLICATION FORM ( 備註 : 如有需要, 請另頁填寫, 並於每頁附加的紙張寫上你的姓名及簽署 ) (Remarks: Attach additional sheet(s) if required, with your name and signature on each.) LE1 5

20 D 部 Section D 附註 : Note : 聲明 Declaration 下面所載聲明, 必須在衞生署內一位監誓員面前宣誓 簽署及填妥 在一位公證人面前辦理亦可 The following declaration must be sworn, signed and completed before a Commissioner for Oaths in Department of Health or a Notary Public. 1. 本人, 是香港身份證號碼 / 身份證明文件號碼 : ( 如非 ( 姓名 ) 香港身份證持有人, 請註明身份證明文件種類 : ) 持有人, 謹以至誠聲明, 本人 在此份參加香港中醫藥管理委員會中醫執業資格試的申請書內所填報的各項詳情及夾附的所有文件及資料均屬確實 2. 本人明白須遵守香港中醫藥管理委員會中醫組所訂定的考試規則, 包括 中醫執業資格試考生手冊 申請書以及 考 生須知 內所列各項 基於考試保密原則, 本人明白並接受在任何情況下中醫組均不會向外及本人公開考試資料, 包 括試題及參考答案等 3. 本人授權香港中醫藥管理委員會中醫組按其認為合適的方式核實此申請書所提供的資料 4. 本人明白根據 中醫藥條例 第 107 條的規定, 任何人藉作出或交出, 或藉導致作出或導致交出, 口頭或書面的任何 虛假或有欺詐成分的申述或聲明而欺詐地促致或企圖促致其本人或任何其他人, 獲得註冊為註冊中醫, 即屬犯罪, 一 經循公訴程序定罪, 可處監禁 3 年 5. 本人明白向香港中醫藥管理委員會中醫組提交個人資料的目的是作為審核本人參加中醫執業資格試的申請及安排考試的用途 6. 本人明白所提交的個人資料, 主要由香港中醫藥管理委員會內部使用, 但亦可能因以上第 5 段所列目的, 向香港考試及評核局 ( 用作安排考試 ) 及其他政府部門 中介機構或行政管理機構披露 除此之外, 本人的個人資料祇會在本人同意下, 又或是 個人資料 ( 私隱 ) 條例 所容許下, 才會向其他人士或機構披露 7. 本人明白根據 個人資料 ( 私隱 ) 條例 第 18 條及 22 條以及其附表 1 第 6 原則所述, 本人有權查閱及修正個人資料 查閱資料時, 可能要繳交費用 本人的個人資料如有任何更改, 須盡快以書面通知香港中醫藥管理委員會秘書處 (a) I, holder of H.K. Identity Card No. / Identification Document No.: (for (Name in Full) applicants without Hong Kong Identity Card, please specify Identification Document Type: ), solemnly and sincerely declare that all the information and particulars given by me in this application form (with all attached documents) for taking the Chinese Medicine Practitioners Licensing Examination of the Chinese Medicine Council of Hong Kong are true and correct. (b) I understand that I shall abide by the examination regulations set by the Chinese Medicine Practitioners Board of the Chinese Medicine Council of Hong Kong, including those stipulated in the Candidates Handbook, Application form, and the Guidance Notes for Candidates. In line with the principle of confidentiality, I understand and accept that under no circumstances will the Chinese Medicine Practitioners Board release any materials used or obtained during the examination including the questions and reference answers etc, to me or the public. (c) I authorize the Chinese Medicine Practitioners Board of the Chinese Medicine Council of Hong Kong to verify the foregoing information in any manner as it deems fit. (d) I understand that according to Section 107 of the Chinese Medicine Ordinance, any person who fraudulently procures or attempts to procure himself or any other person to be registered as a registered Chinese medicine practitioner, by making or producing, or causing to be made or produced, any false or fraudulent representations or declaration, either oral or in writing, commits an offence and is liable on conviction upon indictment to imprisonment for 3 years. (e) I understand that my personal data given to the Chinese Medicine Practitioners Board of the Chinese Medicine Council of Hong Kong are for the purposes of processing my application for taking the Chinese Medicine Practitioners Licensing Examination and arranging for the examination. (f) I understand that my personal data are mainly for use within the Chinese Medicine Council of Hong Kong, but they may also be disclosed to the Hong Kong Examinations and Assessment Authority (for examination arrangements) and to other Government bureaux/departments, agencies or authorities for the purposes mentioned in paragraph (e) above, if required. Apart from this, my personal particulars and information will only be disclosed to parties where I have given consent to such disclosure or where such disclosure is allowed under the Personal Data (Privacy) Ordinance. (g) I understand that I have the right of access and correction with respect to personal data as provided for in Sections 18 and 22 and Principle 6 of Schedule 1 of the Personal Data (Privacy) Ordinance. A fee may be imposed for complying with a data access request. If there is any amendment to my personal data, I shall send it in writing to the Secretariat of the Chinese Medicine Council of Hong Kong as soon as possible. 申請人簽署 : Applicant s Signature: 請在此貼上申請人近照 Attach a Recent Photograph of the Applicant Here 此項聲明是在於年月日在本人面前提出 Declared at this of. (day) (month, year) 監誓員或公證人簽署 監誓員或公證人姓名 身份 / 職位 (Signature of Commissioner (Name of Commissioner Designation/Post for Oaths or Notary Public) for Oaths or Notary Public) 警告 : 根據刑事罪行條例 ( 香港法例第 200 章 ) 第 36(a) 條的規定, 凡宣誓而作失實聲明者, 均屬違法 違例者可被判入獄兩年及罰款 CAUTION: It is an offence under Section 36(a) of the Crimes Ordinance (Chapter 200 of the Laws of Hong Kong) to make a false statement in a statutory declaration. The penalty is imprisonment for two years and a fine. LE1 6

21 E 部 Section E 注意 : 以下證明書, 須由發出該等學位的大學或有關機構的院長 教務處處長或獲授權人員填寫, 並連同申請書一併交回秘書處 N.B.: The following certificate should be completed by the dean, the director of academic affairs office or an authorized officer of the university or the institute awarding the degree by virtue of which the application is made. An official chop of the institution should also be provided. 茲證明 ( ) ( 申請人姓名 ) ( 香港身份證號碼 / 身份證明文件號碼 ) 由 年 月 日至 年 月 日在 ( 大學名稱 ) 修讀 ( 課程名稱 ) 並已圓滿地完成該中醫執業訓練本科學位課程, 及參加有關考試, 成績合格, 而據本人所知, 這部分所載全部資料, 確實無訛 I certify that ( ) (Name of Applicant) (H. K. ID No./Identification Document No.) had attended the (Name of Course) at (Name of University) from (date) until (date) and passed the examinations and satisfactorily (Name of Course) completed the undergraduate degree course of training in Chinese medicine practice listed above and that all the information given in this section is, to the best of my knowledge and belief, true and correct. 院校蓋章 SEAL/OFFICIAL CHOP OF INSTITUTE 簽署 : Signature: 姓名 ( 請用正楷 ): Name in BLOCK LETTERS: 職位 : Position held: 院校名稱 : Name of Institute: 聯絡電話 : Contact Telephone Number: 傳真號碼 : Fax Number: 日期 : Date: LE1 7

22 以上所述的中醫執業訓練本科學位課程及畢業實習的詳細資料如下 : Details of the above undergraduate degree course of training in Chinese medicine practice and clinical training are as follows: 第一年 1st Year 全部科目 ( 包括畢業實習訓練 ) All Subjects (including Clinical Training) 由 From 年 Year/ 月 Month 修讀日期 Duration of study 至 To 年 Year/ 月 Month / / 學習時數 Study Hours 第二年 2nd Year 第三年 3rd Year 第四年 4th Year 第五年 5th Year 年 Year/ 月 Month 年 Year/ 月 Month / / 年 Year/ 月 Month 年 Year/ 月 Month / / 年 Year/ 月 Month 年 Year/ 月 Month / / 年 Year/ 月 Month 年 Year/ 月 Month / / 第六年 6th Year 年 Year/ 月 Month 年 Year/ 月 Month / / 請註明以上學位課程是否在校全時間制 ( 請在適當方格內加上 號) Please indicate if the above degree course is conducted full-time on campus. 是 Yes 否 No (Please in the appropriate box) 請註明以上課程是否函授課程或網授課程或自學考試課程或其他遙距課程 ( 請在適當方格內加上 號) Please indicate if the above course is a correspondence course or web-based 是 Yes 否 No course or self-learning course or other forms of distance learning. (Please in the appropriate box) 中醫藥科目的總學習時數 ( 不包括畢業實習 ) Total study hours of Chinese medicine subjects (excluding clinical training) 上述課程的總學習時數 ( 不包括畢業實習 ) Total study hours of the above course (excluding clinical training) 畢業實習時間 Duration of clinical training during the last year of the undergraduate degree course 院校蓋章 SEAL/OFFICIAL CHOP OF INSTITUTE LE1 8 周 weeks 簽署 : Signature: 姓名 ( 請用正楷 ): Name in BLOCK LETTERS: 職位 : Position held: 院校名稱 : Name of Institute: 聯絡電話 : Contact Telephone Number: 傳真號碼 : Fax Number: 日期 : Date: 及 and 時數 study hours

23 須呈交的文件清單 填妥的申請書 (D 部聲明必須在衞生署內一位監誓員或 在一位公證人面前宣誓 簽署及填妥 ) 申請費港幣 1,340 元 * 香港身份證 / 身份證明文件 ( 公證 / 鑑證影印副本 ) * 院校發出的畢業證書 ( 公證 / 鑑證影印副本 ) * 院校發出的學位證書 ( 公證 / 鑑證影印副本 ) * 院校發出的成績單 ( 公證 / 鑑證影印副本 ) * 院校發出的畢業實習證明 ( 公證 / 鑑證影印副本 ) * 院校發出的修讀地點證明 ( 公證 / 鑑證影印副本 ) 由發出該等中醫學位的大學或有關機構的院長 教務處處長或獲授權人員填寫的院校證明書 ( 正本 ) - 載於申請書 E 部第 7 及 8 頁 附註 * 以掛號郵遞呈交考試申請的人士, 必須連同香港身份證或身份證明文件 院校發出的畢業證書 學位證書 成績單 畢業實習證明 修讀地點證明及其他所需文件的公證影印副本 (notarized photocopies), 一併提交 如申請人親身遞交申請書及向秘書處職員出示上述文件的正本供核對, 所呈交的文件副本便無須經過公證 9

24 CHECKLIST OF REQUIRED ITEMS Completed application form (With the Declaration at Section D sworn, signed and completed before a Commissioner for Oaths in Department of Health or a Notary Public) Application fee of Hong Kong Dollars 1,340 * Hong Kong Identity Card/Identification Document (notarized photocopy) * Graduate certificate issued by the school (notarized photocopy) * Degree certificate issued by the school (notarized photocopy) * Transcript of academic record issued by the school (notarized photocopy) * Transcript of clinical training record issued by the school (notarized photocopy) * Transcript of record of place of study issued by the school (notarized photocopy) Certificate (original) issued by the dean, the director of academic affairs office or an authorized officer of the university or institute awarding the degree in Chinese Medicine as printed in Section E, pages 7 and 8 of the application form. Note * Notarized photocopies of the HKID Card or Identification Document, graduate certificate / degree certificate / transcript of academic record / transcript of clinical training record / transcript of record of place of study of all subjects issued by the school and any other necessary documents should be attached for applicants who submit the application by registered mail. If ap plicants submit the application and present th e originals of the above documents i n person for verification purpose, their photo copies need not be notarized. 10

25 F 部 Section F 認收信 Acknowledgement Letter 由申請人填寫 只供內部填寫 2017 年中醫執業資格試申請書認收信 ( 請填上你的姓名和地址 ) 姓名 : 地址 : 先生 / 女士 : 香港中醫藥管理委員會中醫組已收到你的 2017 年中醫執業資格試申請書 中醫組現正處理你的申請, 你的申請編號是 如你的個人資料有任何更改或你有任何查詢, 請與香港中醫藥管理委員會秘書處聯絡 聯絡電話及地址如下 : 電話 :(852) 地址 : 香港灣仔皇后大道東 213 號胡忠大廈 22 樓 2201 室 查詢時請註明你的申請編號 To be Completed by the Applicant Acknowledgement of the Application Form for Taking the 2017 Chinese Medicine Practitioners Licensing Examination (Please print your name and address.) Name: Address: Official use only Dear Mr./Ms., The Chinese Medicine Practitioners Board of the Chinese Medicine Council of Hong Kong acknowledges receipt of your application form for taking the 2017 Chinese Medicine Practitioners Licensing Examination. Your application is being processed and your application number is. If there is any amendment to your personal data or you have any enquiries, please contact the Secretariat of the Chinese Medicine Council of Hong Kong as follows: Tel No. : (852) Address : Rm 2201, 22/F, Wu Chung House, 213 Queen s Road East, Wanchai, Hong Kong. Please quote your application number when making enquiry. LE1 11