香 港 海關
CUSTOMS AND EXCISE DEPARTMENT
持牌金錢服務經營者的補充資料表格Supplementary Information Sheet for
Licensed Money Service Operators

香港海關專用For Official Use Only
Receipt Date:
Sheet No.
Data Input date:

香港法例 第 615 章《打擊洗錢及恐怖分子資金籌集條例》(打擊洗錢條例)Anti-Money Laundering and Counter-Terrorist Financing Ordinance,
Chapter 615
請用正楷及黑色筆填寫表格。
Please fill in the form in capital letter and black ink.
第 1 部 - 持牌金錢服務經營者的一般資料
Part 1 - General Information of the Licensed Money Service Operator (MSO)
金錢服務經營者牌照號碼
MSO Licence No.
業務 / 法團名稱 (英文)Name of Business / Corporation (in English)

業務 / 法團名稱 (中文)Name of Business / Corporation (in Chinese)
商業登記號碼
Business Registration No.

-第 2 部 - 持牌金錢服務經營者委任的合規主任的詳情 [見於註 1]
Part 2 - Particulars of the Compliance Officer (CO) appointed by the Licensed MSO [see Note 1]
英文姓名(*先生/太太/小姐/女士)
Name in English (*Mr/Mrs/Miss/Ms)(先寫姓氏後寫名字 Surname first then other names)
中文姓名(如適用)
Name in Chinese (if applicable)
香港身份證號碼 或
Hong Kong Identity Card No. or
旅遊證件
Travel Document

類別 Type 獨資經營者兼任
Sole Proprietorserves as CO在公司擔任的職位Position in Company 合夥人兼任Partner serves
as CO( 護照Passport)

其他，請註明：—
Others, please specify:-

號碼 No.
 董事兼任
Director serves
as CO

委任日期 (日/月/年)
Date of Appointment (dd/mm/yyyy)
教育程度
Education Level 最終擁有人兼任
Ultimate Ownerserves as CO 僱員Employee

聯絡電話號碼
Contact Telephone No.


中學程度Secondary level專上程度
Post-secondary level
其他，請註明Others, please specify:-註:如有超過 1 名合規主任，請影印本頁，以填寫其他合規主任的詳情。
Remarks: If you have more than one Compliance Officer (CO), please make a photocopy of this page for filling in theparticulars of the other CO.
* 請删去不適用者 * Please delete as appropriate
請在適當方格內加上 “✓” 號 Please “✓” as appropriate
CED 407 (Rev. 12/2022)

1

香 港 海關
CUSTOMS AND EXCISE DEPARTMENT
持牌金錢服務經營者的補充資料表格Supplementary Information Sheet for
Licensed Money Service Operators
第 3 部 - 持牌金錢服務經營者委任的洗錢報告主任的詳情 [見於註 1]
Part 3 - Particulars of the Money Laundering Reporting Officer (MLRO) appointed by the Licensed MSO[see Note 1]

請述明持牌金錢服務經營者所委任的合規主任是否同時獲委任為洗錢報告主任：—
Please indicate whether the CO appointed by the Licensed MSO is also appointed as the MLRO: 是 Yes(如「是」，請跳到第 4 部)
(If ‘Yes’, please go to Part 4)
 否 No(如「否」，請提供洗錢報告主任的詳情 )(If ‘No’, please provide MLRO’s particulars)

英文姓名 (*先生/太太/小姐/女士)
Name in English (*Mr/Mrs/Miss/Ms)(先寫姓氏後寫名字 Surname first then other names)

中文姓名(如適用)
Name in Chinese (if applicable)
香港身份證號碼 或
Hong Kong Identity Card No. or
旅遊證件
Travel Document

類別 Type( 護照Passport)

其他，請註明：—
Others, please specify:-

號碼 No.
 獨資經營者兼任
Sole Proprietor
serves as MLRO 合夥人兼任Partner serves
as MLRO 最終擁有人兼任
Ultimate Ownerserves as MLRO

 董事兼任
Director servesas MLRO 僱員Employee

在公司擔任的職位
Position in Company
委任日期 (日/月/年)
Date of Appointment (dd/mm/yyyy)
教育程度
Education Level

聯絡電話號碼
Contact Telephone No.
中學程度Secondary level專上程度
Post-secondary level

其他，請註明Others, please specify:-

註:
如有超過 1 名洗錢報告主任，請影印本頁，以填寫其他洗錢報告主任的詳情。
Remarks: If you have more than one Money Laundering Reporting Officer (MLRO), please make a photocopy of thispage for filling in the particulars of the other MLRO.
註1:

根據打擊洗錢及恐怖分子資金籌集指引(指引)第 3.5 段，持牌金錢服務經營者為有效執行打擊洗錢條例，須委任一名合規主任及一名洗錢報告主任。
Note 1: Under para. 3.5 of AMLO Guideline for MSO (Guideline), a licensed MSO should appoint a Compliance
Officer and a Money Laundering Reporting Officer for effective implementation of the AMLO.

* 請删去不適用者 * Please delete as appropriate
請在適當方格內加上 “✓” 號 Please “✓” as appropriate
CED 407 (Rev. 12/2022)

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香 港 海關
CUSTOMS AND EXCISE DEPARTMENT
持牌金錢服務經營者的補充資料表格Supplementary Information Sheet forLicensed Money Service Operators

第 4 部 - 屬合夥的持牌金錢服務經營者的資金資料 (只適用於持牌人屬合夥)Part 4 –Partnership Funds of the Licensed MSO which is a partnership (only applicable to the licensee which is aPartnership)

請提供合夥資金的金額:Please provide the amount of Partnership Funds:-$

第 5 部 - 請提供有關顧客的資料
Part 5 –Please provide information relating to customer(1)

聯絡顧客的主要方式
Main communication with customer

 電郵
E-Mail(2) 電話
Telephone 書信
Letters 面對面
Face to Face

顧客的主要居住地方
Main residence of customers

 本地Local 內地Mainland 海外，請註明：Overseas, please specify* 請删去不適用者 * Please delete as appropriate
請在適當方格內加上 “✓” 號 Please “✓” as appropriateCED 407 (Rev. 12/2022)

3

 其 他 ， 請 註 明 ：Others, please specify:-

香 港 海關
CUSTOMS AND EXCISE DEPARTMENT
持牌金錢服務經營者的補充資料表格Supplementary Information Sheet for
Licensed Money Service Operators

第 6 部 -在香港以外地方經營金錢服務的分行及附屬企業的資料 (只適用於香港成立的法團 ) [見於註 2]Part 6 – Information of Branches and Subsidiary Undertakings operating a money service outside Hong Kong
(Only applicable to the corporation incorporated in Hong Kong) [see Note 2]
請述明持牌金錢服務經營者有沒有在香港以外地方經營金錢服務的分行及/或附屬企業：Please indicate whether the Licensed MSO has any branches and/or subsidiary undertakings operating a moneyservice outside Hong Kong:-1.



有 Yes沒有 No(  分 行 branches
及 and(如「沒有」，請跳到第 7 部) 附屬企業 subsidiary undertakings )(If ‘No’, please go to Part 7)
請述明在香港以外地方經營金錢服務的分行及附屬企業的數目：
Please indicate the number of branches and subsidiary undertakings operating a money service outside HongKong:-

2.

(a) 在香港以外地方經營金錢服務的分行的數目
No. of branches operating a money service outside Hong Kong(b) 在香港以外地方經營金錢服務的附屬企業的數目
No. of subsidiary undertakings operating a money service outside Hong Kong
在香港以外地方經營金錢服務的分行及附屬企業的註冊地址
Registered address(es)of the Branches and Subsidiary Undertakings operating a money service outside Hong Kong3.

 分行 branches*室 / 店鋪號碼*Flat / Room / Shop No.

 附屬企業 subsidiary undertakings
樓Floor座
Block No.

大厦名稱
Building Name
*屋邨 / 屋苑名稱Estate / Court Name
門牌號碼Street No.

道路/街道名稱Road/Street Name

*地區 / 區域District / Area
*城市 / 市鎮
City / Town
國家 / 地域
Country / Region
郵政編碼
Postal Code
備註:

如有超過 1 間在香港以外地方經營金錢服務的分行及附屬企業，請影印本頁，用以填寫其他分行及附屬企業的詳情。
Remarks: If you have more than one branch and subsidiary undertaking operating a money service outside HongKong, please make a photocopy of this page for filling in the particulars of the other branches andsubsidiary undertakings.
註2:

根據指引第 3.16 段，持牌金錢服務經營者應在當地法律准許的範圍內，確保它們在外地的分行或附屬企
業設有集團的打擊洗錢/恐怖分子資金籌集政策。
Note 2: Under para. 3.16 of the Guideline, a licenced MSO’s overseas branches and subsidiary undertakings shouldobserve similar AML measures of the licensed MSO to the extent permitted by the law of that place.
* 請删去不適用者 * Please delete as appropriate請在適當方格內加上 “✓” 號 Please “✓” as appropriate
CED 407 (Rev. 12/2022)

4

香 港 海關
CUSTOMS AND EXCISE DEPARTMENT
持牌金錢服務經營者的補充資料表格Supplementary Information Sheet for
Licensed Money Service Operators

第 7 部 -提交此補充資料表格人士的聲明 (見於第 7 部內的備註)Part 7 – Declaration by the person who submits this supplementary sheet (see Remarks in Part 7)
本人謹此聲明：I declare that:(a)在本表格提供的所有詳情及資料(包括附加頁) 共頁，全屬真確無誤。
the particulars and information given in this form (including additional sheet) consisting ofpage(s) are true and correct.

(b)

本人承諾採取措施，以確保如本補充資料表格內所提供的詳情有任何改變，持牌人須在自改變發生之日起計的一個月內，藉書面向海關關長具報有關改變；I undertake that actions shall be taken to ensure that the licensee must notify the Commissioner of Customs
and Excise in writing of any change in the particulars that are provided in this supplementary sheet within one
month beginning on the date on which the change takes place.

(c)

本人承諾確保每名獲委任的合規主任及洗錢報告主任都已閱讀於此補充資料表格的收集個人資料聲明。
I undertake that actions shall be taken to ensure that each of the appointed Compliance Officer and Money
Laundering Reporting Officer has read the Personal Information Collection Statement in this Supplementary
Sheet.

(*持牌人 / 獲授權的合夥人 / 董事或人士
簽署及公司印章)(*Signature of the Licensee / authorized person of thepartnership / authorized person of the corporation andcompany chop)( 姓 名 ( 正 楷 ))(Name in block letters)(*香港身份證 /旅遊證件號碼)(*HKID No. /Travel Doc. No.)

(在持牌人業務/法團擔任的職位)(Position in the Licensee’s Business/Corporation)(聯絡電話號碼)(Contact Tel. No.)

(日期)
(Date)

備註:
提交此補充資料表格的人士必須是：—
Remarks: The person who submits this supplementary sheet must be:(a) 如持牌人屬獨資經營，該獨資經營者；the sole proprietor, if the licensee is a sole proprietorship;(b) 如持牌人屬合夥，則獲每名合夥人書面授權的合夥人，並應隨附授權書；the partner authorized in writing by every partner, if the licensee is a partnership.
letter should be attached;

The authorization(c) 如持牌人屬法團，則獲董事局書面授權的董事或人士，並應隨附授權書。
the director or the person, authorized in writing by the Board of Directors, if the licensee is a corporation.
The authorization letter should be attached.
請 將填妥的持牌金錢服務經營者的補充資料表格呈交 :Please submit the completed Supplementary Information Sheet for Licensed Money Service Operators to:香港海關 金錢服務監理科 九龍九龍灣常悅道 11 號 新明大廈 4 樓 402-403 室
Money Service Supervision Bureau Customs and Excise Department
Units 402-403, 4/F, Centre Parc, 11 Sheung Yuet Road, Kowloon Bay, Kowloon* 請删去不適用者 * Please delete as appropriate
請在適當方格內加上 “✓” 號 Please “✓” as appropriate
CED 407 (Rev. 12/2022)

5

香 港 海關
CUSTOMS AND EXCISE DEPARTMENT
持牌金錢服務經營者的補充資料表格Supplementary Information Sheet for
Licensed Money Service Operators

收集個人資料聲明Personal Information Collection Statement
1.

收集目的
Purpose of Collection
本補充資料表格所提供的個人資料及任何更新資料，將會用於處理申請 / 記錄用途 / 更新紀錄 及 進行調
查，藉以執行第 615 章《打擊洗錢及恐怖分子資金籌集條例》(打擊洗錢條例) 的規定。
The personal data provided in the supplementary sheet as well as any updates will be used for facilitatingprocessing of applications / record purpose / record update and investigations for the enforcement of the AntiMoney Laundering and Counter-Terrorist Financing Ordinance (AMLO), Chapter 615.

2.

資料轉介
Classes of Transferees
在本表格填報的個人資料及任何更新資料，可能會向其他政府部門 / 政策局或機構披露，以履行上文
第 1 段所載的目的；或根據打擊洗錢條例第 49 條向任何第三者披露；或在法律授權或規定的情況下須作
出此等披露。
The personal data you provide in this form as well as any updates of them may be disclosed to other
Government departments / bureaux or organizations for the purposes mentioned in paragraph 1 above; or any
third parties under section 49 of the AMLO; or where such disclosure is authorized or required by law.

3.

查閱個人資料
Access to Personal Data
根據《個人資料﹝私隱﹞條例》(私隱條例)的規定，你有權查閱及更正你的個人資料。查閱的權利包括有權索取此表格內填報的個人資料的複本。根據私隱條例的規定，本署有權收取合理費用，以處理任何查閱資
料要求。
You have the right of access to and correction of your personal data as provided for in the Personal Data(Privacy) Ordinance (PDPO). Your right of access includes the right to obtain a copy of your personal data
provided in this form. In accordance with the provision of the PDPO, we have the right to charge a reasonable
fee for the processing of any data access request.

4.

個人資料的查詢
Enquiries to Personal Data如欲查詢本表格所收集的個人資料，包括查閱及更正資料要求，請聯絡：
Enquiries concerning the personal data collected by this form, including the request for access to and correctionof personal data, should be addressed to:香港北角渣華道222號
海關總部大樓31樓
香港海關
內務行政科
內務秘書

* 請删去不適用者 * Please delete as appropriate
請在適當方格內加上 “✓” 號 Please “✓” as appropriate
CED 407 (Rev. 12/2022)

Departmental Secretary
Office of Departmental Administration
Customs and Excise Department
31/F, Customs Headquarters Building
222 Java Road, North Point, Hong Kong.

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