中藥材零售商牌照申請表 FORM 1A

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1 香港中醫藥管理委員會香港法例第 549 章中醫藥條例填寫中藥商牌照申請表須知填寫申請表前, 必須先閱讀以下填表須知一般事項 1. 請沿虛線剪下所需的申請表格及文件核對表 2. 請用黑色墨水筆或原子筆填寫申請表 3. 申請人須填妥申請表各項 ( 包括中英文地址 ), 並提供正確資料 4. 除註明外, 請以正楷中文或英文填寫申請表格 5. 申請人如未能提供所需的資料, 或所填寫的資料未能清楚顯示申請人符合最基本的申請規定, 申請將不獲受理 6. 如申請表或文件核對表不敷應用, 可自行複印 7. 申請人應保留一份填妥的申請表, 以及所需提交的資料副本, 以備參考 8. 衞生署中醫藥事務部收到申請表後, 會在 30 天內發出認收信, 以確認收到有關申請認收信內會註明申請人的申請編號申請人如在 30 天後仍未收到認收信, 請即聯絡衞生署中醫藥事務部 1/2

2 個人資料 ( 私隱 ) 政策為保障個人資料私隱, 衞生署以個人資料 ( 私隱 ) 條例 ( 條例 ) 附表 1 載列的六項保障資料原則為藍本, 制訂保障資料政策本署尊重個人資料私隱, 並承諾會全面落實和遵行保障資料原則, 以及條例的所有相關條文查閱及更正個人資料的要求有關查閱及更正資料的要求和查詢, 請向衞生署負責收集該等個人資料的相關辦事處或診所提出, 並應填妥查閱資料要求表格 < 以提出有關要求本署處理任何查閱資料的要求, 將會收取合理的費用根據執行中醫藥條例 ( 香港法例第 549 章 ) 而收集的個人資料衞生署中醫藥事務部會收集根據執行中醫藥條例而需的個人資料, 而有關資料將會存儲及用於將來與處理中成藥註冊中藥商發牌及執法的事宜上就查詢及更正因用作執行中醫藥條例收集的個人資料, 請聯絡中醫藥事務部高級藥劑師 ( 中醫藥 ), 聯絡地址為 : 九龍觀塘巧明街 100 號 Landmark East 友邦九龍大樓 16 樓欲知更多有關實施個人資料 ( 私隱 ) 條例的資料, 請瀏覽個人資料私隱專員公署的網站 < 2/2

3 表格 Form 1A 檔案編號 File Reference No: 中醫藥條例 Chinese Medicine Ordinance ( 香港法例第 549 章 ) (Cap. 549) 中藥材零售商牌照申請表 Application Form for Retailer Licence in Chinese Herbal Medicines 本公司地址為 We, ( 公司名稱 Name of Company),at ( 公司地址 Address of Company), 現根據中醫藥條例第 114 條的規定, 申請於下述的處所零售中藥材 We wish to apply for conducting retail business of Chinese herbal medicines at the premises below in accordance with Section 114 of the Chinese Medicine Ordinance. 甲部 Part A 營業資料 Business Information 營業處所公司名稱 Company name of business premises 營業處所地址 Address of business premises ( 中文 ): (Chinese) ( 英文 ): (English) ( 中文 ): (Chinese) ( 英文 ): (English) 商業登記號碼 Business Registration No.: 營業電話號碼 Business Tel No.: 電子郵件地址 ( 如適用 ) Address (if any).. 營業傳真號碼 Business Fax No.: 請在適當的方格內加上號 Please tick in the appropriate box. 1/3

4 貯存倉地址及商業登記號碼 ( 如與上述地址不同 ) Address of Warehouse and Business Registration No. (if different from above): 獨資東主 / 合夥人 / 董事姓名及其香港身分證號碼 / 護照號碼 ( 如董事為一間公司, 請填寫公司名稱及公司編號 ) Name and Hong Kong Identity Card Number/Passport Number of sole proprietor/partners/director(s). (In case of a director being a corporation, please state the name and Company Number of the corporation): 申請經營有關的中藥材 ( 可選擇多於一項 ): Please specify the Chinese herbal medicines to which the application relates (can select more than one option): 附表 1 藥材 Schedule 1 medicine 附表 2 藥材 Schedule 2 medicine 申請人請述明會否在申請所關乎的處所內進行中藥材配發 *, 如選擇不會, 則無須提名負責監管中藥材配發人員及填寫有關人員的資料 ( 中藥規例第 32 條 ) Please state that whether Chinese herbal medicines will be dispensed* in the premises to which the application relates or not. If not, there will be no need to nominate the responsible person for the supervision of dispensing of Chinese herbal medicines and fill in the relevant information of that person. ( Section 32 of the Chinese Medicines Regulation): 本公司會配發中藥材 will dispense Chinese herbal medicines We 不會配發中藥材 will NOT dispense Chinese herbal medicines * 註 : 根據中醫藥條例, 配發指根據或按照任何註冊中醫或表列中醫開出的處方而調配和供應中藥材 Note: Pursuant to the Chinese Medicine Ordinance, dispense means the preparation and supply of Chinese herbal medicines on or in accordance with a prescription given by a registered Chinese medicine practitioner or a listed Chinese medicine practitioner. 負責監管中藥材配發人員的資料 Information of the responsible person nominated for the supervision of the dispensing of Chinese herbal medicines 獲提名負責監管中藥材配發人員獲提名負責監管中藥材配發人員的副手的資料 ( 不多於 2 名 ) The deputy or deputies who are nominated to be responsible for the 的資料 supervision of the dispensing of Chinese herbal medicines (not more than 2 The person who is nominated to be persons) responsible for the supervision of the dispensing of Chinese herbal medicines 請在適當的方格內加上號 Please tick in the appropriate box. 2/3

5 乙部 Part B 聲明 Declaration 1. 本人謹此聲明, 就本人所知及所信, 此申請表及有關的核對表所提供的資料, 皆屬真確事實的全部 I hereby declare that all the foregoing information in this application form and the relevant checklist is FULL, COMPLETE and TRUE to the best of my knowledge and belief. 2. 本人授權香港中醫藥管理委員會中藥組按其認為合適的方式, 核實此申請所提供的資料 I authorize the Chinese Medicines Board of the Chinese Medicine Council to verify the foregoing information in any manner as it deems fit. 3. 本人明白根據中醫藥條例第 153(3) 條的規定, 任何人在向中藥組提出申請或在給予任何資料時, 在要項上作出他知道是虛假或他不相信是真實的陳述或申述, 即屬犯罪, 最高可處第 6 級罰款及監禁 2 年 I understand that according to Section 153(3) of the Chinese Medicine Ordinance, any person who, in making an application to the Chinese Medicines Board or in giving any information, makes a statement or representations which he knows to be false or does not believe to be true in a material particular, commits an offence and shall be liable to maximum penalty of a fine at level 6 and to imprisonment for 2 years. 4. 本人明白所提交的個人資料, 將會用作執行中醫藥條例的條款 I understand that the personal data provided by me are for the purposes of facilitating the execution of the provisions of the Chinese Medicine Ordinance. 5. 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 4 段所列目的, 向其他政府部門中介機構或行政管理機構披露 ; 除此以外, 這些資料只會在本人同意, 又或是個人資料 ( 私隱 ) 條例所容許下, 才會向其他人士披露 I understand that the personal data provided by me are mainly for use within the Chinese Medicine Council but they may also be disclosed to other Government bureaux/departments, agencies or authorities for the purposes mentioned in paragraph (4), if required. Apart from this, the information provided herein 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. 6. 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, 但查閱資料時, 可能要繳交費用本人的個人資料如有任何更改, 須盡快以書面通知衞生署中醫藥事務部 I understand that I have the right of access and correction with respect to personal data as provided for in Section 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 the personal data, I shall send it in writing to the Chinese Medicine Division of the Department of Health as soon as possible. 公司負責人簽署 Signature of person in charge of the business 姓名 ( 正楷 )Name (Block Letters) 公司蓋章 Company Chop 職位 Position Held 日期 Date 此欄供有關部門填寫 For Office Use Only 收到申請表日期 Date of receipt of application form: 3/3

Microsoft Word - (web)_F.1_Notes_&_Application_Form(Chi)(non-SPCCPS)_16-17.doc

Microsoft Word - (web)_F.1_Notes_&_Application_Form(Chi)(non-SPCCPS)_16-17.doc 聖保羅男女中學學年中一入學申請申請須知申請程序 : 請將下列文件交回本校 ( 麥當勞道 33 號 ( 請以 A4 紙張雙面影印, 並用魚尾夾夾起 : 填妥申請表並貼上近照小學五年級上下學期成績表影印本課外活動表現及服務的證明文件及