License Number* Required 須填寫 Name of clinic 診所名稱* Required 須填寫 Clinic Phone 診所電話* Required 須填寫 Clinic email address 診所電子郵件* Required 須填寫 Clinic Website 診所網站 Applicant's title 申請人稱謂DrMrMrsMsProf Applicant's surname 申請人姓氏 Applicant's given name(s) 申請人名字 Medical Council of Hong Kong registration number 申請人之香港醫務委員會註冊號碼 Email 申請人電郵地址 Office phone 申請人辦公室電話 Mobile 申請人聯絡電話 Is the applicant in Part 2 the official representative of your Clinic in the Federation if your membership is approved? 假若您們機構被確認為香港私營醫療機構聯會會員，第二部的申請人是否你們機構的代表？ Yes 是No 不是 Representative's Title 代表稱謂DrMrMrsMsProf Representative's Surname 代表姓氏 Representative's Given Name(s) 代表名字 Medical Council of Hong Kong Registration Number 代表之香港醫務委員會註冊號碼 Office Phone 代表辦公室電話 Mobile 代表聯絡電話 Email 代表電郵地址 I declare that, the above information provided on this form in support of my application is accurate and complete. 現聲明此表格內本人所填寫的資料均屬準確及詳盡．Yes 是Please confirm online payment amount. Alternatively, please make an ATM transfer or write out a cheque with the following information. 請確認網上繳費金額，你也可以進行自動櫃員機轉帳或郵寄支票，銀行戶口資料如下：Account holder 帳戶持有人: The Federation of Private Healthcare Centres of Hong Kong LtdBank name 銀行名稱: Bank of CommunicationsBank account number 銀行帳號: 382537102354702Mailing address for cheques (please quote the name of your clinic at the back of your cheque) 支票郵寄地址（請在支票背面註明您診所的名稱）: The Federation of Private Healthcare Centres of Hong Kong, 6/F, Virtus Medical Tower, 122 Queen's Road Central, Hong KongEmail address for ATM transfer receipts (please quote the name of your clinic) 自動櫃員機轉賬收據的電郵地址（請註明您的診所名稱）: [email protected] Payment methodPay now with credit card 立即以信用咭付款Pay later with other methods 稍後以其它方法付款 Please confirm credit card payment amount 請確認以下信用咭繳費金額HK$5000.00: includes one-off registration fee ($3000) and first-year membership dues ($2000) / 港幣五千元正；包含一次性註冊費($3000)及首年會費 ($2000) Submit 遞交表格ResetNotes 注意事項:Applicants may be asked to provide further information/details for the consideration of the Federation Council. 申請人有可能會被要求提供更多資料以供本會之委員會作審批用途。Membership fees: 會員費包括:one-time registration fee of HK$3000 per member (incl. a non-refundable application processing fee of HK$500) 一次性註冊費港幣三千元正（已包含不可退回之報名手續費港幣五百元正）；annual dues, first year, HK$2000 及每年會費港幣二千元正。Applicants shall pay both sums by credit card during the online application process. 申請人必須於網上註冊時以信用卡同時繳交註冊費及首年會費。Secretariat will notify shortlisted applicants individually by email after the approval of the Federation Council. 秘書處將會與成功通過本會之委員會審批的申請人作個別聯絡。For further inquiries, please contact the Secretariat at [email protected] or +852 3893 9371. 如有查詢，請聯絡秘書處：電郵：[email protected]；電話：+852 3893 9371
