PDF《香港特别行政区政府入境事务处》

- - - - 香港特别行政区政府入境事务处 此栏由办理机关填写 For Official Use Only Appn Ref: A.

Letter C/L Required CiPer / CbPo Fee Immigration Department The Government of the Hong Kong Special Administrative Region 出入境纪录证明申请表 Application for a Statement of Travel Records 注意 Note: 1. 填写本表格前,请先阅读背页的「填表须知」 . Others: Please read Notes for guidance overleaf before completing this form. 2. ? 请於适当方格内加上「?」号. Pleasetickasappropriate. 警告 Warning : 如就此项申请作任何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. 第I 部 所申请的出入境纪录 Part I The Travel Records being applied 资料当事人的资料 Particulars of the data subject: Maiden surname (if applicable) 姓名 (中文) (如适用) Name in Chinese (if applicable) 姓 (英文) Surname in English 名 (英文) Given names in English 别名 (如有) Alias (if any) 婚前姓氏 (如适用) 性别?男 ?女 出生 日期 Male Female Date of Sex birth 日dd 月mm 年yyyy 香港身份证号码 (如有) HK Identity Card no.(if any) 国籍 Nationality ( ) 旅行证件号码 Travel Document no. 所需出入境纪录的日期时段 Required travel records period: 第II部 申请人资料及声明 Part II Particulars and Declaration of theApplicant 由From 日dd 月mm 年yyyy 至to 日dd 月mm 年yyyy 资料用途 The data will be used for: 本人,即下方签署人,现按以下身份作出此项申请 I, the undersigned, make this application in my capacity as: 是上述资料的当事人.The data subject of the above-mentioned travel records. 是代表上述资料当事人作出的.本人*对上述未成年的资料当事人有作为父母亲的责任 / 已获资料当事人书面授权 / 已由法庭委任 以处理资料当事人该等事务. On behalf of the above-mentioned data subject. I * have parental responsibility for the data subject who is a minor / am authorized in writing by the data subject / am appointed by a Court to manage the affairs of the data subject. 申请人签署 (请参阅填表须知第五段) Signature of applicant (Please see Note 5) 申请人姓名 Full name (Surname first) 通讯地址 Correspondence Address *(请将不适用者删去,并参阅填表须知第四段) * (PleasedeletewhereinappropriateandseeNote4) 此栏由办理机关填写 For Official Use Only Fee Paid 日期 Date 电话号码 Telephone No. Register No. Receipt No. Receiving Officer: (Signature/Name/Post) Date Application checked in order. Remarks Case Officer: (Signature/Name/Post) Date Application approved/refused. Remarks Authorising Officer: (Signature/Name/Post) Date STR posted to applicant by registered mail. Serial No. Remarks By: (Signature/Name/Post) Date ID

697 (2/2011)

5 填表须知

一、领取本表格毋须缴费.

二、本表格可用中文或英文填写,请用黑色或蓝色笔以正楷填写本表格.

三、本处未能提供十年前的出入境纪录.

四、此项申请所需的文件 (i) 资料当事人的身份证明文件 (例如旅行证件) 载有其个人资料及签名式样专页的副本;

(ii) 资料当事人的香港身份证副本 (访港旅客除外);

及(iii) 如申请人并非资料当事人 (例如:是未成年资料当事人的父、母亲或已获资料当事人书面授权的人士), 除需提供自己及资料当事人有关上列 (i) 和(ii) 的文件外,还须提交文件证明申请人替资料当事人取 得上述出入境纪录的资格,例如:授权书、资料当事人的出生证明书副本、法庭命令副本等.

五、本表格须由申请人签署.签名式样须与所递交的身份证明文件 (例如旅行证件) 副本上的签名相同.

六、申请出入境纪录证明所需的费用,可参阅收费表 (ID 912).

七、递交申请书 (i) 申请书可用邮递方式寄回香港湾仔告士打道七号入境事务大楼入境事务处纪录中心;

(ii) 申请人递交申请书时,必须连同上述所需的文件及须缴付的费用一并递交本处.申请人须以划线支票、 银行汇票或本票缴费,并注明支付「香港特别行政区政府」 .请勿邮寄现金.期票通常不获接受;

及(iii) 请连同申请书交回已妥姓名和回邮地址的邮寄标签 (ID 839) 及认收通知卡 (ID 697A).

八、出入境纪录证明的签发 本处在收妥所需文件后,一般需时大约十个工作天处理有关申请 (工作天是指星期一至星期五,公众假期除 外).申请结果将会用已由申请人妥姓名和回邮地址的邮寄标签 (ID 839) 以挂号邮件方式寄回申请人.

九、查询 申请人可在本处网页 http://www.immd.gov.hk/chtml/faq.htm 浏览一些常见问题的答案.如有任何查询或需要更 多资料,请致电

2824 6111 或以图文传真方式:2877

7711 或透过

网址:www.immd.gov.hk,向入境事务处提出. Notes for guidance 1. This form is issued free of charge. 2. This form may be completed in Chinese or English. Please complete this form in BLOCK letters using black or blue pen. 3. Travel records earlier than preceding ten years are not available. 4. Documents required for the application (i) One photocopy of the particulars and signature pages of the data subject'

s proof of identity (e.g. travel document);

(ii) One photocopy of the data subject'

s Hong Kong Identity Card (except for visitor to Hong Kong);

and (iii) If applicant is not the data subject (e.g. being the parent of the data subject who is a minor or being authorized in writing by the data subject), then on top of providing both the data subject'

s and the applicant'

s supporting documents stated at (i) and (ii) above, submission of documents which can sufficiently prove the applicant'

s eligibility to obtain the travel records will also be required (e.g. authorization letter, copy of data subject'

s birth certificate, copy of court order, etc.). The form must be signed by the applicant. The signature should be identical to that on the copy of proof of identity (e.g. travel document) submitted. 6. The fee for a Statement of Travel Records is shown on the fee leaflet (ID 912). 7. Submission of application (i) Application can be sent by post to the Records Centre, Immigration Department, Immigration Tower,

7 Gloucester Road, Wan Chai, Hong Kong;

(ii) The application must be submitted together with the above-mentioned supporting documents and payment required by crossed cheque, bank draft or cashier order payable to The Government of the Hong Kong Special Administrative Region . Cash should not be sent through post. Post-dated cheque will not normally be accepted;

and (iii) Please return the application with a completed Mailing Label (ID 839) and a self-addressed Acknowledgement Card (ID 697A). 8. Issue of Statement of Travel Records It normally takes around

10 working days to process an application for a Statement of Travel Records upon receipt of all necessary documents (working days mean Monday to Friday excluding General Holidays). The result of the application will be sent to the correspondence address completed by the applicant on the Mailing Label (ID 839) by registered mail. 9. Enquiries You can browse for the answers to frequently asked questions in the Immigration Department'

s website at http://www.immd.gov.hk/ehtml/faq.htm. If you have any enquiries or need more information, please contact the Immigration Department on telephone number:

2824 6111 or by fax:

2877 7711 or through website: www.immd.gov.hk. 收集个人资料的目的 收集资料的目的 申请表格内所提供的个人资料,入境事务处会用作下列一项或多项的用途:- (甲) 办理你的申请;

(乙) 实施/执行《入境条例》(第115 章)及《入境事务条例》(第331 章)的有关条文规定,以及履行入境管制职务,藉此协 助其他政府决策局和........