Fillable Form for Countersignature (in connection with an application (Workplace English Campaign)

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Form for Countersignature (in connection with an application (Workplace English Campaign)

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Country of origin: HONG-KONG
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香港特別行政區政府
入境事務處
Immigration Department
,
the Government of the
Hong Kong Special Administrative Region
副署事項表格
(
供申請香港特別行政區旅行證件使用
)
Form for Countersignature (in connection with an application for a HKSAR travel document)
注意
1.
任何年滿十八歲並認識申領證件兒童的人士
(
除該兒童的父母或監護人外)，均可作為副署人。
2.
副署人必須填寫及簽署本表格及在該童相片的左下方，
跨越相片邊及表格簽署
。副署人無須前來本處。
3.
申請人須將副署人已填妥及簽署的本表格，連同副署人的香港身份證或載有副署人簽名的有效旅行證件
的影印本，一併交來本處。
4.
本表格免費派發。
警告
副署人請注意：根據香港特別行政區法律的規定，任何人士，不論是為其本人或他人獲取旅行證件而作
出虛假陳述，即屬違法。
NOTE
1.
Any person (except the parent or guardian of the child) who is aged 18 or above and knows the child can act as
the counter-signatory.
2.
The counter-signatory should complete this form and sign across the bottom left corner of the child’s
photograph and the form. Personal attendance of the counter-signatory is NOT required.
3.
The applicant should produce this form, duly completed and signed by the counter-signatory, together with a
copy of the counter-signatory’s Hong Kong identity card or valid travel document bearing the
counter-signatory’s signature.
4.
This form is issued free of charge.
WARNING
Persons who countersign the application are warned that the making of an untrue statement for the purpose of
procuring, whether for himself or any other person, any travel document is an offence under the laws of the
Hong Kong Special Administrative Region.
I. 副署人的資料
PARTICULARS OF COUNTER-SIGNATORY
中文姓名
英文姓名
Name in English
香港身份證
旅行證件類別
及號碼
H.K. identity card / type and number
聯絡電話號碼
Contact tel. no.
II. 聲明書 (
由副署人填寫及簽署
)
DECLARATION (To be completed and signed by the counter-signatory)
本人，即下開簽署人，現證明在右方所貼出的相片為_____________________
(該童的姓名)
的真像，並證明本人在表格內所填報的資料均屬正確無誤。
I, the undersigned, certify that the photograph affixed on the right hand side is the
true likeness of _____________________________ , and that to the best of my knowledge
(name of the child)
and belief, the information given in this form is correct.
___________________________________ ___________________
副署人簽署
Signature of counter-signatory
日期
Date
該童的照片
Photograph
of the child
此欄由辦理機關填寫
FOR OFFICIAL USE ONLY
申請書檔號
Application Reference No.
_____________________________________________________________ _________________________________
辦理職員簽署，姓名及職位 Signature, name and post of accepting officer 日期
Date
ID 641(11/2018)
_____________________
副署人跨越相片邊簽署
Signature across the photograph
注意：
請用黑色或藍色筆以正楷填寫本表格。
Note: Please complete this form in BLOCK
letters using black or blue pen.
可輸入資料 Fillable Form
列印 Print
重設 Reset
收集資料的目的
你在本表格內所提供的個人資料，會供入境事務處作下列一項或多項用途：
(甲) 辦理本表格第 II 項所載的兒童的申請；
(乙) 實施／執行《香港特別行政區護照條例》(第 539 章)、《入境條例》(第 115 章) 及《入境事務隊條例》(第 331 章) 的有關條
文規定，以及履行入境管制職務，藉此協助其他政府決策局和部門執行其他法例和規例；
(丙) 在有關人士向入境事務處提出申請並提名你為保證人或諮詢人時，將你的資料供作核對用途；
(丁) 作統計及研究用途，但所得的統計數字或研究成果，不會以能辨識各有關的資料當事人或其中任何人的身份的形式提供；以
及
(戊) 作法例規定、授權或准許的其他合法用途。
在本表格內提供個人資料純屬自願。如果你未能提供足夠資料，本處可能無法辦理有關的申請。
資料披露對象的類別
為了上述目的，你在本表格上所提供的個人資料，或會向其他政府決策局和部門及其他機構披露。
查閱個人資料
根據《個人資料(私隱)條例》(第 486 章) 第 18 及 22 條，以及附表 1 第 6
項原則，你有權要求查閱和改正個人資料。你的查閱權利包
括在繳交有關費用後，索取你在本表格上所提供個人資料的副本。
如對本表格所收集的個人資料有任何查詢，包括查閱或改正有關資料，可向下列人員提出：
香港中環
統一碼頭道 38 號
海港政府大樓 2 樓
總入境事務主任(證件管理)
電話 : 2852 3646
Purpose of Collection
The personal data provided in this form will be used by Immigration Department for one or more of the following purposes:-
(a) to process the application of the child mentioned at part II;
(b) to administer/enforce relevant provisions of the Hong Kong Special Administrative Region Passports Ordinance (Chapter 539), the
Immigration Ordinance (Chapter 115) and Immigration Service Ordinance (Chapter 331), and to assist in the enforcement of any
other Ordinances and Regulations by other government bureaux and departments through carrying out immigration control duties;
(c) to process other person’s application for immigration facilities in which you are named as a sponsor or referee;
(d) to serve statistical and research purposes on the condition that the resulting statistics or results of the research will not be made
available in a form which will identify the data subjects or any of them; and
(e) for any other legitimate purposes as may be required, authorised or permitted by law.
The provision of personal data by means of this form is voluntary. If you do not provide sufficient information, we may not be able to
process the related application.
Classes of Transferees
The personal data provided in this form may be disclosed to government bureaux, departments and other organisations for the purposes
mentioned above.
Access to Personal Data
You have the right to request access to and correction of your personal data as provided for in sections 18 and 22 and Principle 6 of Schedule
1 of the Personal Data (Privacy) Ordinance (Chapter 486). Your right of access includes the right to obtain a copy of your personal data
provided in this form subject to payment of a fee.
Enquiries concerning the personal data collected by means of this form, including making access and corrections, should be addressed to:-
Chief Immigration Officer (Documents Management)
2
nd
Floor, Harbour Building
38 Pier Road
Central, Hong Kong
Tel. No.: 2852 3646
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Form for Countersignature (in connection with an application (Workplace English Campaign)

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Completed 25 May 2021

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