香 港 海 關
CUSTOMS AND EXCISE DEPARTMENT
表 格 4
要求批准擔任持牌人的合夥人 / 董事 / 最終擁有人申請書
Form 4
Application for Approval in respect of Persons Proposing to become
Licensee’s Partners / Directors / Ultimate Owners

香港海關專用For Official Use Only
Receipt Date:
Application No.:
Approval Date:

香港法例 第 615 章《打擊洗錢及恐怖分子資金籌集條例》
Anti-Money Laundering and Counter-Terrorist Financing Ordinance,
Chapter 615
請用正楷及黑色筆填寫表格。填寫本表格前，請先閱讀填表須知。
Please fill in the form in capital letter and black ink and read the Guidance Notes before completing this form.
第 1 部 - 申請人的一般資料Part 1 - General Information of the Applicant
金錢服務經營者牌照號碼Money Service Operator 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 -個人擬任持牌人的合夥人 / 董事 / #最終擁有人的詳情Part 2 - Particulars of the proposed Individual to be Licensee’s Partner / Director / #Ultimate Owner#(最終擁有人 - 請參閱填表須知第 1.3 段 ) (Ultimate Owner - Please refer to Para. 1.3 of the Guidance Notes)(1)

個人擬任合夥人 / 董事 / 最終擁有人的詳情
Particulars of the proposed Individual Partner / Director / Ultimate Owner 合夥人 Partner

 董事 Director

英文姓名(*先生/太太/小姐/女士)
Name in English (*Mr/Mrs/Miss/Ms)

先填寫姓氏再填寫名字 Surname first then other names

中文姓名(如適用)
Name in Chinese (if applicable)
中文電碼(如適用)
Chinese Commercial Codes (if applicable)
出生日期(日/月/年)
Date of Birth (dd/mm/yyyy)
出生地點
Place of Birth
國籍
Nationality*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 402 (Rev. 12/2022)

最終擁有人 Ultimate Owner

別名(如有)
Alias (if any)1

香 港 海 關
CUSTOMS AND EXCISE DEPARTMENT
表 格 4
要求批准擔任持牌人的合夥人 / 董事 / 最終擁有人申請書
Form 4
Application for Approval in respect of Persons Proposing to become
Licensee’s Partners / Directors / Ultimate Owners
第 2 部 -個人擬任持牌人的合夥人 / 董事 / 最終擁有人的詳情(續)Part 2 - Particulars of the proposed Individual to be Licensee’s Partner / Director / Ultimate Owner (Continued)(1)

個人擬任合夥人 / 董事 / 最終擁有人的詳情(續)Particulars of the proposed Individual Partner / Director / Ultimate Owner (Continued)

教育程度
Education Level

中學程度
Secondary level
專上程度
Post-secondary level
其他, 請註明
Others, please specify:-

香港居民適用 For Hong Kong Resident
香港身份證號碼Hong Kong Identity Card No.

()

非香港居民適用 For non-Hong Kong Resident
旅遊證件類別(例如護照)
Travel Document Type(e.g.Passport)
旅遊證件號碼
Travel Document No.
簽發日期
Date of Issue

日

D月

DM

屆滿日期
Date of Expiry

年

M

YYYY

日

D D年

月

M

M YYY

Y

Y

Y

YY

簽發國家 / 地點Country / Place of Issue(2)

在申請人業務 / 法團擔任的職位及聯絡資料
Position in the Applicant’s Business / Corporation and contact information

在公司擔任的職位
Position in Company

受聘日期
Date of Appointment

日D D年月MM聯絡電話號碼
Contact Telephone No.
(3)同意擔任持牌人的合夥人 / 董事 / 最終擁有人
Consent to act as a partner / director / ultimate owner of the licensee

本人同意擔任持牌人的*合夥人 / 董事 / 最終擁有人，以海關關長批准此申請為準。
I consent to act as a *partner / director / ultimate owner of the licensee subject to the approval to be granted by theCommissioner of Customs and Excise in respect of this application.

(擬任 *合夥人 / 董事 / 最終擁有人 簽署)(Signature of the proposed *partner / director / ultimate owner)

註:Remarks:(姓名(正楷))(Name in block letters)(日期)(Date)

如有超過 1 名合夥人 / 董事 / 最終擁有人(屬個人)，請影印本申請表格第 2 部，以填寫其他合夥人
/ 董事 / 最終擁有人的詳情。
If there is more than one partner / director / ultimate owner who is an individual, please make a photocopy ofPart 2 of this application form for filling in the particulars of the other partner / director / ultimate owner.

*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 402 (Rev. 12/2022)

2

香 港 海 關
CUSTOMS AND EXCISE DEPARTMENT
表 格 4
要求批准擔任持牌人的合夥人 / 董事 / 最終擁有人申請書Form 4Application for Approval in respect of Persons Proposing to become
Licensee’s Partners / Directors / Ultimate Owners
第 3 部 - 法團擬任持牌人的合夥人 / 董事的詳情Part 3 - Particulars of the Proposed Corporate to be Licensee’s Partner / Director(1)

法團擬任合夥人 / 董事的詳情
Particulars of the proposed Corporate Partner / Director合夥人 Partner



董事 Director

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.

-屆滿日期(日/月/年)
Expiry Date (dd/mm/yyyy)
公司編號
Company No.
註冊日期 (日/月/年)

成立日期(日/月/年)
Date of Incorporation (dd/mm/yyyy)(只適用於非香港公司)

Date of Registration (dd/mm/yyyy)(for non-Hong Kong company only)

成立地點
Place of Incorporation
業務性質
Nature of Business
電郵地址
E-mail Address辦事處電話號碼
Office Telephone No.
(2)

辦事處傳真號碼
Office Fax No.

法團的註冊地址
Registered address of the Corporation*室 / 店鋪號碼*Flat / Room / Shop No.
大厦名稱
Building Name
*屋邨 / 屋苑名稱*Estate / Court Name
門牌號碼Street No.
地區 /區域(例如灣仔)District /Area (e.g. Wanchai)*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 402 (Rev. 12/2022)

樓Floor座
Block No.

道路 / 街道名稱
Road/Street Name
 香港 HK  九龍 KLN  新界 NT 香港特區以外 OTHER THAN HKSAR

3香 港 海 關
CUSTOMS AND EXCISE DEPARTMENT
表 格 4
要求批准擔任持牌人的合夥人 / 董事 / 最終擁有人申請書
Form 4
Application for Approval in respect of Persons Proposing to become
Licensee’s Partners / Directors / Ultimate Owners
第 3 部 -擬任持牌人的法團合夥人 / 董事的詳情(續)Part 3 - Particulars of the Proposed Corporate to be Licensee’s Partner / Director (Continued)(3)

同意擔任合夥人 / 董事Consent to act as a partner / director

本人已獲

( 該公司) 授權，證實該公司同意擔任持牌人的(擬任法團的名稱)*合夥人 / 董事，以海關關長批准此申請為準。現夾附有關授權書。
I, being authorised by the(the Company), confirm that the Company(Name of the Proposed Corporation)consents to become a partner / director* of the licensee subject to the approval to be granted by the Commissioner ofCustoms and Excise in respect of this application. The authorization letter is attached.

(擬任法團的獲授權人士簽署)(Signature of the authorized personof the Proposed Corporation)

註:Remarks:(姓名(正楷))(Name in block letters)(日期)(Date)

如有超過 1 名屬法團合夥人 / 董事，請影印本申請表第 3 部，以填寫其他合夥人 / 董事的詳情。
If there is more than one corporate partner/director, please make a photocopy of Part 3 of this application
form for filling in the particulars of the other partner / director.

*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 402 (Rev. 12/2022)

4

香 港 海 關
CUSTOMS AND EXCISE DEPARTMENT
表 格 4
要求批准擔任持牌人的合夥人 / 董事 / 最終擁有人申請書
Form 4
Application for Approval in respect of Persons Proposing to become
Licensee’s Partners / Directors / Ultimate Owners第 4 部 –提交此申請表格人士的聲明 (見於第 4 部內的備註) (請於會見時簽署及蓋章)
Part 4 –Declaration by the person who submits this application form (see Remarks in Part 4) (Please sign and stamp
at the time of interview)
本人謹此聲明：I declare that:-(a) 在本申請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 application form (including supplementary sheets) consisting ofpage(s) are true and correct.
(b) 本人明白根據香港法例第 615 章《打擊洗錢及恐怖分子資金籌集條例》(打擊洗錢條例)第40條，持牌人
必須在自資料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事項。本人更明白無合理
辯解而違反此項規定，即屬犯罪，一經定罪，可被判罰款 50,000 元。
I understand that under section 40 of the Anti-Money Laundering and Counter-Terrorist Financing Ordinance,Chapter 615 (AMLO), a licensee must notify the Commissioner of Customs and Excise in writing of any change inthe particulars within one month beginning on the date on which the change takes place. I further understand thatany breach of this requirement, without reasonable excuse, is an offence and is liable on conviction to a fine of$50,000.
(c) 本人已閱讀要求批准擔任持牌人的合夥人/ 董 事/ 最終擁有人申請表格4 的填表須知第C 部所載的收集個人資料聲明，以及明白當中內容。
I have read the Personal Information Collection Statement stated in Part C of the Guidance Notes on Form 4
Application for Approval in respect of Persons proposing to become Licensee’s Partners/Directors/UltimateOwners and understand the contents stated therein.

(*持牌人 / 獲持牌人授權的合夥人 / 董事或人士
簽署及公司印章)(*Signature of the licensee / authorized person of the licensed
partnership / authorized director or person of the licensed
corporation and company chop)(姓名(正楷))(Name in block letters)(*香港身份證 /旅遊證件號碼)(*HKID /Travel Doc. No.)

(聯絡電話號碼)(Contact Telephone No.)

(日期)
(Date)(會見時簽署及蓋章)(to be signed and stamped at the time of interview)(在持牌人業務 / 法團擔任的職位)(Position in the Licensee’s Business / Corporation)
見證人 :Witnessed by :
備註:

(簽署)
(Signature)(海關人員的姓名及職位)(Name and Post of C&ED officer)(日期)(Date)

提交此申請表格的人士必須是：

Remarks: The person who submits this application form 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. The authorization letter should be attached;(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* 請删去不適用者 * Please delete as appropriate
請在適當方格內加上“” 號 Please insert a “” in the appropriate box
CED 402 (Rev. 12/2022)5

要求批准擔任持牌人的合夥人 / 董事 / 最終擁有人申請須遞交的證明文件的核對清單
Checklist for submission of supporting documents for Application for Approval in respect of Persons
Proposing to become Licensee’s Partners / Directors / Ultimate Owners
1.

每一名個人擬任合夥人 / 董事 / 最終擁有人詳情的證明文件 (於會面時遞交)Supporting Documents of Particulars of each proposed individual partner / director / ultimate owner(submitted during the interview)
香港居民 已填妥的適當人選聲明表格 3A 連同附錄 I 及 II
Hong Kong resident
Completed Fit and Proper Person Declaration Form 3A together with Appendices I & II 香港身份證複本A copy of Hong Kong Identity Card
非香港居民
 已填妥的適當人選聲明表格 3A 連同附錄 I 及 II
Non-Hong Kong
Completed Fit and Proper Person Declaration Form 3A together with Appendices I & IIresident
 旅遊證件的個人資料頁的複本
A copy of the Bio-data page of the Travel Document
2. 每一名法團擬任合夥人 / 董事的詳情的證明文件 (與申請表格一併遞交)Supporting Documents of Particulars of each proposed corporate partner / director (submitted together withthe application form)
本地公司 已填妥的適當人選聲明表格 3B
Completed Fit and Proper Person Declaration Form 3B
Local company
 有效商業登記證的複本
A copy of valid Business Registration Certificate
 公司註冊證書的複本
A copy of Certificate of Incorporation
 組織章程大綱及章程細則的複本
A copy of Memorandum and Articles of Association
非香港公司
 已填妥的適當人選聲明表格 3B
Non-Hong Kong
Completed Fit and Proper Person Declaration Form 3Bcompany
 有效商業登記證的複本
A copy of valid Business Registration Certificate
 非香港公司的註冊證明書的複本
A copy of Certificate of Registration of non-Hong Kong Company
 組織章程大綱及章程細則的複本
A copy of Memorandum and Articles of Association
非在香港註冊的法  已填妥的適當人選聲明表格 3B
團
Completed Fit and Proper Person Declaration Form 3B
Corporation not 公司註冊證書的複本或其根據香港法例第 32B 章《公司(表格)規例》第 3 條等同的經核
registered in Hong證的公司註冊證書複本Kong
A copy of the Certificate of Incorporation or its equivalent certified in accordance with reg. 3 ofthe Companies (Forms) Regulations, Chapter 32B
授權書 (與申請表格一併遞交)Authorization letter (submitted together with the Application Form)合夥人 經所有合夥人簽署的授權書複本
Partner
A copy of the authorization letter signed by all partners
法團 經董事局簽署的授權書複本
Corporation
A copy of the authorization letter signed by the Board of Directors
3.

請隨已填妥的申請表格夾附已蓋上申請人公司印章的證明文件。海關的獲授權人員會在與申請人會面時查驗文
件的正本。
Please attach the supporting documents (stamped with the applicant’s company chop) to the completed applicationform. Authorized officers of C&ED will examine the originals during the interview with the applicant.
已填妥的申請表格連同證明文件，應遞交香港海關金錢服務監理科辦理。
The completed application form together with the supporting documents should be submitted to the Money Service
Supervision Bureau of the Customs and Excise Department.
地址
九龍九龍灣常悅道11號
新明大廈4樓402-403室
香港海關
金錢服務監理科
Address
Money Service Supervision Bureau
Customs and Excise Department
Units 402-403, 4/F, Centre Parc,
11 Sheung Yuet Road, Kowloon Bay, Kowloon

CED 402 (Rev. 12/2022)

辦公時間星期一至星期五(公眾假期除外)

上午 8 時 45 分至中午 12 時 30 分
下午 1 時 30 分至 5 時 30 分

Office hours
Monday to Friday(Except public holidays)

8:45 a.m. to 12:30 p.m.
1:30 p.m. to 5:30 p.m.