表格 FORM:LE3 申請編號 : Application No.: 香港中醫藥管理委員會 The Chinese Medicine Council of Hong Kong 2017 年中醫執業資格試第 II 部分臨床考試報名表 Enrolment Form for Sitting the 2017 Chinese Medicine Practitioners Licensing Examination Part II Clinical Examination 香港法例第 549 章 中醫藥條例 Chinese Medicine Ordinance (Cap. 549) 此報名表只適用於已通過第 I 部分筆試的申請人 This enrolment form is only for the applicants who have passed the Part I - Written Examination. 申請人必須把已填妥的報名表, 於 2017 年 3 月 31 日 ( 星期五 ) 或之前, 連同所需費用, 以掛號郵遞方式 1 或親身送達香港中醫藥管理委員會秘書處 逾期報名, 恕不接受 申請人亦可以繳費靈繳付所需費用 如以掛號郵遞方式遞交報名表, 則以郵戳日期為準 Applicants must submit the enrolment form together with the prescribed fees to the Secretariat of the Chinese Medicine Council of Hong Kong by registered post or in person on or before 31 March 2017 (Friday). Late enrolments will not be accepted. Applicants may pay the prescribed fees by using Payment by Phone Service (PPS) 1. For enrolments submitted by post, the post mark will be taken as the submission date. A 部付款方法 Section A Payment Method 支票 Cheque 繳費靈 PPS 請註明使用繳費靈的繳費日期 : Please fill in the PPS Payment Date: B 部個人資料 ( 請以正楷書寫 ) Section B Personal Particulars (Please write in BLOCK LETTERS). 中文姓名 Name in Chinese 英文姓名 ( 先寫姓氏 ) Name in English (Surname first) 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) 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) 簽發機關 Issuing Authority 請在適當方格內加上 號 Please in the appropriate box. 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: 中醫執業資格試只備有中文試卷 2: The Licensing Examination Papers are printed in Chinese only. LE3 1
C 部第 II 部分臨床考試 Section C Part II Clinical Examination 在第 I 部分筆試中取得合格的考生, 才可參加第 II 部分臨床考試 Candidates who have passed Part I Written Examination are eligible for taking Part II Clinical Examination. 本人已於 ( 年份 ) 在第 I 部分筆試中取得合格, 考試的申請編號是 I passed Part I Written Examination in (Year) and my application number is. 第 II 部分 臨床考試 Part II Clinical Examination 請選擇應考臨床考試的語言 : Please choose the language for the Clinical Examination: 粵語 Cantonese 普通話 Putonghua 請在此貼上申請人近照 Attach a Recent Photograph of the Applicant Here 申請人簽署 Applicant s Signature 日期 Date 如申請人的通訊地址 聯絡電話 傳真號碼或電郵地址有所更改, 請填寫 D 部 請填寫中英文地址 If there is a change in the applicant s correspondence address, telephone number, fax number or e-mail address, please complete Section D. Please complete the address in both Chinese and English. 請在適當方格內加上 號 Please in the appropriate box. LE3 2
D 部更改地址 電話號碼 傳真號碼或電郵地址 Section D Change of Address, Telephone Number, Fax Number or E-mail Address 姓名 Name 中文通訊地址 Correspondence Address in Chinese 申請編號 Application No. 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) 英文通訊地址 Correspondence Address in English 郵政編碼 (Postal Code / Zip Code) 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) 日間聯絡電話號碼 郵政編碼 (Postal Code / Zip Code) Day Time Contact Telephone No. - - 住宅電話號碼 Residential Telephone No. - - 傳真號碼 Fax No. - - 電郵地址 E-mail Address 國家號碼 Country Code 區域字頭 Area Code LE3 3
請在認收信上填寫申請編號 申請人姓名和地址 Please fill in the application number, the applicant s name and address on the acknowledgement letter. LE3 4
E 部 Section E 認收信 Acknowledgement Letter 由申請人填寫 只供內部填寫 2017 年中醫執業資格試第 II 部分臨床考試報名表認收信 ( 請填上你的申請編號 姓名和地址 ) 申請編號 : 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 年中醫執業資格試第 II 部分臨床考試報名表 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) 2121 1888 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 Enrolment Form for Sitting the 2017 Chinese Medicine Practitioners Licensing Examination Part II Clinical Examination (Please print your application number, name and address) Application No. : 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 enrolment form for sitting the 2017 Chinese Medicine Practitioners Licensing Examination Part II Clinical 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) 2121 1888 Address : Rm 2201, 22/F, Wu Chung House, 213 Queen s Road East, Wanchai, Hong Kong. Please quote your application number when making enquiry. LE3 5