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香港海关CUSTOMS AND EXCISE DEPARTMENT 表格5要求加入新的用以经营金钱服务的处所申请书 Form

5 Application to add New Premises used for the operation of a Money Service 香港海关专用 For Official Use Only Receipt Date: Application No.

: Approval Date: *

1 请删去不适用者*Please delete as appropriate 请在适当方格内加上 ? 号Please ? as appropriate CED

403 (Rev. 03/2018) 香港法例 第615 章《打击洗钱及恐怖分子资金筹集条例》 Anti-Money Laundering and Counter-Terrorist Financing Ordinance, Chapter

615 请用正楷及黑色笔填写表格.填写本表格前,请先阅读填表须知. Please fill in the form in capital letters and black ink and read the Guidance Notes before completing this form. 第1部C申请人的一般资料 Part

1 - General Information of the Applicant 金钱服务经营者牌照号码 Money Service Operator Licence No. 业务 / 法团名称(英文) Name of Business / Corporation (in English) 业务 / 法团名称(中文) Name of Business / Corporation (in Chinese) 商业登记号码 Business Registration No. - 第2部C拟加入用以经营金钱服务的特定处所的资料 Part

2 - Details of the Particular Premises to be added for the operation of a Money Service (1) 处所的资料 Premises information 请述明加入新的用以经营金钱服务的特定处所的情况:― Please state the status for adding new particular premises to operate a money service :- ? 加入新的处所 ? 要求在特定处所经营金钱服务 Adding new premises Application to operate a money service at particular premises ? 在贸易展览会场地加入新的处所 :- Adding new premises in trade fair / exhibition venue:- 日期 (日/月/年) : Date (dd/mm/yyyy) 由From 至to 商业登记号码 Business Registration Number ― 处所的面积 Area of the premises (平方米) (m2 ) 请述明经营金钱服务的处所类别:― Please state the type of premises where the money service is operated:- ? 住宅处所 ? 商业处所 ? 混合住宅及商业处所 Domestic premises Commercial premises Mixed domestic and commercial premises 分行名称(英文)(如有) (商业登记证上所载名称) Branch Name (in English) (if any) (as shown in the Business Registration Certificate) 分行名称(中文)(如有) (商业登记证上所载名称) Branch Name (in Chinese) (if any) (as shown in the Business Registration Certificate) 香港海关CUSTOMS AND EXCISE DEPARTMENT 表格5要求加入新的用以经营金钱服务的处所申请书 Form

5 Application to add New Premises used for the operation of a Money Service *

2 请删去不适用者*Please delete as appropriate 请在适当方格内加上 ? 号Please ? as appropriate CED

403 (Rev. 03/2018) 第2部C拟加入用以经营金钱服务的特定处所的资料(续) Part

2 - Details of the Particular Premises to be added for the operation of a Money Service (Continued) (2) 地址(请用英文填写) Address (Please complete in English) *室/店/铺/摊位及会场号码 *Flat / Room / Shop / Booth &

Hall No. 楼Floor 座Block No. 大厦名称 Building Name *屋/屋苑名称 *Estate / Court name 门牌号码 Street No. 街道名称 Street Name 地区(例如湾仔) District (e.g. Wanchai) ? 香港 ? 九龙 ? 新界 HK KLN NT (3) 联络资料 Contact information 办事处电话号码 Office Telephone No. 办事处传真号码 Office Fax No. (4) 有否其他业务在此处所内经营? (不适用於在贸易展览会场地加入新的营业处所) Is there any other business being run in this premises? (not applicable for adding business premises in trade fair / exhibition venue) ? 有Yes ? 否No (如「有」 ,请提供下述资料 (If '