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香港特别行政区政府入境事务处 Immigration Department, the Government of the Hong Kong Special Administrative Region 香港特别行政区护照申请书 (适用於十六岁以下儿童在香港以外地区的申请) Application for HKSAR Passport (For children under

16 years of age applying outside Hong Kong) 1.

护照类别 Type of Passport 三十二页

32 pages 或or 2. 申请类别 Type of Application 首次申请 First application 或or 换领 Replacement 或or 四十八页

48 pages 因遗失/损毁/更改个人资料的申请 Application due to loss/ damage/amendment of personal particulars 3. 儿童的个人资料 Child'

s Personal Particulars (以香港永久性居民身份证所载者为准 As stated on Hong Kong permanent identity card ) 姓 (中文) Surname in Chinese 姓 (英文) Surname in English 名 (中文) Given names in Chinese 名 (英文) Given names in English 性别 Sex 男Male 女Female 出生日期 Date of birth 此栏由办理 机关处理 For Official Use Only 日dd 月mm 年yyyy 香港永久性居民身份证号码 HK permanent identity card no. ( ) 签发日期 Date of issue (如该儿童未领有香港永久性居民身份证,请於下方填上香港出生证明书号码 (如有)) (If the child does not have HK permanent identity card , please provide HK birth certificate no. below (if any)) 日dd 月mm 年yy 香港缟っ魇楹怕 Hong Kong birth certificate no. ( ) 签发日期 日dd 月mm 年yy 出生地点 Place of birth 中国 China 香港 内地 in Mainland Hong Kong 其他省、直市或自治区 Other province, municipality or autonomous region ( ) 澳门 Macau 其他国家 Other country 现时住址 (请於边界内\写) Present address (Please fill in within border) 父、母/合法监护人联络电话号码 Contact telephone no. of parent/legal guardian 附加资料 (如有) Additional Information (if any) 5. 儿童的父、母或合法监护人声明书 Declaration of Parent or Legal Guardian 本人,即下开签署人,现谨此声明: I, the undersigned, declare that: (1) 本人为上述儿童申请护照. I apply for a passport in respect of the abovenamed child. (2) 本人乃儿童的: My relationship with the child is 母亲 父亲 法庭颁令监护人 获授权的监护人 mother father legal guardian (by court order) legal guardian (by authorisation) (3) 本人对该儿童的监护权并未受任何法院颁令所限制. My rights in respect of the child have not been limited in any way by the order of any court. (4) 该儿童是中国公民,并且从未向香港入境事务处作出有关他/她变更国籍的声明. The child is a Chinese citizen and no declaration of change of nationality has been made to the Immigration Department, Hong Kong, in respect of (5) 本人作此申请时,该儿童身在 When I make this application the child is staying at (6) 就本人所知及相信,此申请书所填报的资料均属正确无误. The information given in this application is correct to the best of my knowledge and belief. (7) 本人同意为处理此申请而须进行的任何查询. I consent to the making of any enquiries necessary for the processing of this application. 中文姓名 Name in Chinese 本人的香港身份证号码 My HK identity card no.: ( ) 英文姓名 Name in English 如非香港居民,请填写 旅游证件类别及号码: For non-Hong Kong resident, please state travel document type and no.: 通讯住址 Correspondence address (如地址同上,便无须\写 No need to provide if same as above) 日期 Date 日dd 月mm 年yyyy 签署 Signature 注意 Note: 请於边界内签署 Please sign within border 注意 (i) Note: 请用黑色或蓝色笔以正楷填写本申请书. Please complete this form in BLOCK letters using black or blue pen. (ii) 警告? Warning: 请在适当方格内填上「?」号. Please tick as appropriate. 如就此项申请作出虚假陈述或填报失实资料,即属违法. ? It is an offence in law to furnish any false statement or information relating to this application. (请注明名称 Please state name) (请注明国家名称 Please state country name only) (请填写国家名称 Please state name of country) him/her. 4. Date of issue ID844(12/2017) 香港谘询人姓名(如有) Name of Referee in H.K.(if any) 香港谘询人电话号码(如有) Referee'