IIR Village Representative Election – Indigenous Inhabitant Representative Application for Change of Registered Particulars

1a. HK IDENTITY CARD NUMBER Prefix Number Check Digit

( ) 2. SEX Male Female

1b. IDENTITY DOCUMENT (Note 6) (If you do not have a Hong Kong Identity Card) (Please attach a copy of such identity document)

Document Type

Number

Issuing Authority 3. INFORMATION AS SHOWN ON THE HK IDENTITY CARD / IDENTITY DOCUMENT

Name in Chinese

in Chinese Commercial Code

Surname

Other Names in Full

Date of Birth (dd / mm / yyyy)

4. PRINCIPAL RESIDENTIAL ADDRESS (Note 12). Please complete in ENGLISH Block Letters.

Flat / Room Floor Block Name of Estate / Building

House No. Name of Village

Number & Name of Street / Lot Number & Demarcation District

District City / Country Postal Code

Home Telephone Number

Mobile Phone Number

Fax Number

E-mail Address □ If you agree to provide the above e-mail address to the candidates of the Village concerned for the purpose of sending election advertisement,

please put a tick “” in this box. Otherwise, the e-mail address will only be used by the Home Affairs Department / Electoral Registration Officerfor communication. The candidates may choose to send election advertisement via e-mail in lieu of hardcopy.

5. CORRESPONDENCE ADDRESS (Remarks: Such data will be provided to candidates. If the applicant is a prisoner, he / she may choose whether or not to provide the address of the correctional institution.) (Note12)

6. LANGUAGE PREFERENCE FOR ELECTION-RELATED COMMUNICATION (Note 13)

Please tick as appropriate : □ Chinese □ English 7. DECLARATION

I declare that the particulars entered in this form are true and accurate, and that

(a) I am eligible to be registered as an elector for an Indigenous Village or a Composite Indigenous Village (Notes 7, 8and 9); and

(b) I am not subject to any disqualification from registration (Note 10); and

(c) I apply to be registered as an elector of Indigenous Inhabitant Representative Election for (Village) of (Rural Committee), as:[Please tick as appropriate (one box only)]□ I am an indigenous inhabitant of this Village; OR□ I am the spouse of an indigenous inhabitant (Name of Spouse) (HK Identity

Card / Identity Document Number of Spouse) of this Village (Note 11).

My consent and authorisation is hereby given to the Home Affairs Department (HAD) / Electoral Registration Officer (ERO), in assessing my eligibility for registration as an elector, to compare and cross check my personal data entered in this application form with my personal data collected by other organisations for any other purposes (whether or not it is collected by manual means) so as to verify if such data are true and accurate. I understand that if the personal data provided by me are false or misleading, the HAD / ERO may take appropriate action against me (including referral of the case to other law enforcement agencies for follow up action). I expressly agree that the HAD / ERO may approach other relevant government departments or public / private organisations for proof of data collected and matching of data. I hereby consent and authorise the relevant government departments (including but not limited to the Registration and Electoral Office, the Housing Department, the Correctional Services Department, the Land Registry, the Immigration Department, the Transport Department, the Inland Revenue Department, and the Companies Registry) or any other public / private organisations (including but not limited to the Hong Kong Housing Society), to release my personal data to the HAD / ERO, so that the HAD / ERO can compare and cross check such data with those on this application form when processing this application and updating the voter registration and election-related records annually. (Note 14)

Date : Day Month Year

Signature :

R E F - 1 b ( E n g l i s h Ve r s i o n ) ( 2 0 1 8 ) P l e a s e Tu r n O v e r

I MPORTANT: Please read the accompanying guidance notes before completing this form in BLOCK LETTERS. A person who makes any statement which the

person knows to be false in a material particular or recklessly makes any statement which is incorrect in a material particular or knowingly omits any material particular commits an offence under the law.

The statutory deadline for application for change of principal particulars (i.e. name) by a registered elector is 16 June of the same year while forrequest for change of other particulars (including principal residential address, correspondence address or the Indigenous Village / CompositeIndigenous Village to be registered) is 16 July of the same year (Note 2 and 3).

Application Reference No

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FOR OFFICIAL USE ONLY

Work Code (HQ)

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Please ensure that you have completed/attached the items below before submitting the application form:

Fill in the HK Identity Card / Identity Document Number clearly

Attach a copy of identity document (if you have to update your identity document number)

Sign the application form

Note : You may return this application form by post or by FAX to 2591 6392.

FOLD HERE

Electoral Registration Officer Home Affairs Department 30/F, Southorn Centre 130 Hennessy Road Wan Chai, Hong Kong

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BUSINESS REPLY SERVICE LICENCE NO. 商業回郵牌號﹕7410

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Village Representative Election - Indigenous Inhabitant Representative Application for Change of Registered Particulars

Guidance Notes (Please keep this Guidance Notes for reference)

(1) This form is used for repor t ing change of regis tered par t icu lars by a registered e lec tor ofIndigenous Inhabitant Representat ive Elec t ion for an Indigenous Vi l lage or a Composi teIndigenous Vi l lage. I f you are not yet a regis tered e lector and wish to be registered as an e lectorof Indigenous Inhabitant Representat ive Elect ion, you must complete the appl icat ion form“Vi l lage Representat ive Elect ion – Indigenous Inhabi tant Representat ive: Appl icat ion for NewVoter Regis trat ion” (REF-1a) instead of this appl icat ion form.

(2) For inclus ion in the f ina l register of e lectors to be publ ished in October every year, the s tatutorydeadl ine for appl icat ion for change of pr inc ipal par t icu lars ( i .e . name) by a registered e lec tor is16 June of the same year . Please note that for Indigenous Inhabitant Representat iveElect ion, pr inc ipal resident ia l address is not a pr incipal part icu lar in the f ina l register ofe lec tors .

(3) For inclus ion in the f ina l register of e lectors to be publ ished in October every year, the s tatutorydeadl ine for request for change of other part icu lars ( inc luding pr inc ipal res ident ia l address,correspondence address or the Indigenous Vi l lage / Composite Indigenous Vi l lage to beregis tered) by a regis tered e lector is 16 July of the same year.

(4) You may check your latest registrat ion part icu lars through the Rural Representat ive Elect ionWebsite (www.had.gov.hk/rre) or by cal l ing the Rural Representat ive Elec t ion Hot l ine (21521521). Elec tors have the responsib i l i t y to update their regis trat ion par t icu lars wi th the HomeAffa irs Depar tment (HAD) / Electoral Regis trat ion Off icer (ERO) as soon as poss ib le i f thepar t icu lars (e.g.pr inc ipal res ident ia l address) have changed.

(5) The above deadl ines refer to the date on which an appl icat ion form reaches the HAD / ERO.Appl icat ions which reach the HAD / ERO af ter the above deadl ines wi l l be processed for thepurpose of compi l ing the regis ter of e lec tors for the fol lowing year. Please submit th isappl icat ion form to the HAD / ERO by the fo l lowing means:(a) by post (Address: Home Affa irs Department , 30/F, Southorn Centre, 130 Hennessy Road,

Wan Chai , Hong Kong (or to any Dis tr ic t Off ices of the HAD)) ; or(b) by fax (No. : 2591 6392); or(c) in person or by a representat ive to the HAD Headquarters or Home Affa irs Enquiry Centres

of any Distr ic t Off ices of the HAD; or(d) by emai l (email address: rre@had.gov.hk), wi th the s igned appl icat ion form scanned and

attached as an emai l a t tachment ; or(e) by us ing the e lec tronic form and uploading the completed and s igned form to the HAD

(webs ite: www.had.gov.hk/rre) .

(6) I f you do not have a Hong Kong Ident i t y Card, you may provide other ident i t y document that isacceptable as proof of your ident i t y (e.g. passpor t) . Please attach a copy of such ident itydocument to the appl ication form (the photocopies should include the front cover of theidentity document and its other pages showing the personal particulars, ident itydocument number, photograph, as wel l as the expiry date of the document). The HAD / EROwi l l compi le the register of e lectors according to the name and the ident i t y document numberyou entered in the appl icat ion form. W hen you vote, p lease produce the or ig inal ident i t ydocument as recorded in the regis ter.

(7) General ly speak ing, you are el ig ib le to be registered as an e lector for an Indigenous Vi l lage ora Composi te Indigenous Vi l lage i f :(a) you are an indigenous inhabitant (Note 8) of that Vi l lage, or you are the spouse or the

surviving spouse of an indigenous inhabitant of that Vi l lage; and(b) you have reached 18 years of age or wi l l reach 18 years of age on or before the next coming

20 October fo l lowing your appl icat ion for registrat ion; and(c) you hold a val id ident i ty document, e.g. a Hong Kong permanent ident i t y card; and(d) you are not subjec t to any d isqual i f icat ion f rom regis trat ion (Note 10) .

(8) According to the Rural Representat ive Elect ion Ordinance (Cap. 576) , “ ind igenous inhabitant”(原居民 )―

(a) in re lat ion to an Indigenous Vi l lage that exis ted in 1898 (whether or not the name the Vi l lagenow has is the same name i t had in 1898), means―( i) a person who was in 1898 a res ident of the Vi l lage; or( i i ) a person who is descended through the male l ine f rom a person ment ioned in

subparagraph ( i) ;(b) in relat ion to an Indigenous Vi l lage that branched off f rom an Indigenous Vi l lage that ex isted

in 1898 (whether or not the name the Vi l lage now has is the same name it had in 1898),means―( i) a person―

(A) who was at the t ime of the branching off a res ident of the f irs t -ment ionedIndigenous Vi l lage; and

(B) who was an indigenous inhabitant of the second-ment ioned Indigenous Vi l lage; or( i i ) a person who is descended through the male l ine f rom a person ment ioned in

subparagraph ( i) ;(c) in re lat ion to a Composite Indigenous Vi l lage, means―

( i) a person who was in 1898 a res ident of any of the v i l lages of which the Vi l lage iscomposed; or

( i i ) a person who is descended through the male l ine f rom a person ment ioned insubparagraph ( i) .

(9) In compi l ing a provis ional regis ter for an Indigenous Vi l lage or a Composite Indigenous Vi l lage,the ERO shal l s tr ike out the names and other re levant par t icu lars of the persons whom the EROis sat is f ied on reasonable grounds as being not e l ig ib le to have their names inc luded in the f ina lregis ter for the Vi l lage. Such names and other relevant par t icu lars of those persons wi l l beentered on an omissions l is t .

(10) General ly speak ing, persons who are d isqual i f ied f rom registrat ion inc lude persons who:(a) are found under the Menta l Heal th Ordinance (Cap. 136) to be incapable, by reason of

mental incapac ity, of managing and adminis ter ing their proper ty and affa irs; or(b) are members of the armed forces of the People ’s Republ ic of China or any other country or

terr i tory.

(11) I f you are el ig ible to be regis tered as an e lector for two or more Indigenous Vi l lages orComposi te Indigenous Vi l lages, you may be registered for only one of those Vi l lages of yourchoice. The v i l lage named in the appl icat ion form wi l l be regarded as the Vi l lage of your choice.

(12) (a) I f you are not res id ing in Hong Kong, p lease provide a correspondence address in HongKong. I f you are res id ing in Hong Kong but there is no posta l serv ice avai lable for your pr inc ipal res ident ia l address, p lease a lso provide a correspondence address.

(b) I f you are a pr isoner, you may choose to provide the address of the correct ional inst i tut ionwhere you are impr isoned or other address as your correspondence address. I f you chooseto use the address of a correct ional ins t i tu t ion as your correspondence address, p leaseprovide the pr isoner number for easy del ivery of the e lec t ion-re lated mater ia ls wi th in /among the correct ional inst i tu t ions.

(c) Please note that the principal residential address and correspondence address ( ifprovided) wil l be provided to candidates for the purpose of sending election-relatedmaterials to the electors concerned. Please not i f y the HAD / ERO immediate ly in wr i t ingof any subsequent change of your pr inc ipal res ident ia l address, correspondence addressand/or personal part icu lars ( inc luding the status as a spouse of an indigenous inhabitant) .

(13)Under normal c ircumstances, elec t ion-re lated communicat ions issued to e lectors by the HAD /ERO are in both Chinese and Engl ish. This language preference is to fac i l i tate candidates’communicat ion wi th you at e lect ions in the language of your choice. I f you do not complete th ispar t , i t wi l l be assumed that your preferred language is Chinese.

(14)In assess ing your e l ig ibi l i t y for regis trat ion as an e lector, the HAD / ERO wi l l compare and cross

check your personal data entered in the appl icat ion form with your personal data col lected by other organisat ions for any other purposes (whether or not i t is co l lected by manual means) so as to ver i fy i f those data are true and accurate. I f your personal data provided are false or mis leading, the HAD / ERO may take appropr iate ac t ion against you ( inc luding referra l of the case to other law enforcement agenc ies for fo l low up act ion) . Upon s igning the appl icat ion form, you express ly agree the HAD / ERO to approach other re levant government depar tments or publ ic / pr ivate organisat ions for proof of data col lec ted and matching of data, and you hereby consent and author ise the re levant government departments ( inc luding but not l im ited to the Registrat ion and Electora l Off ice, the Hous ing Department, the Correct ional Services Depar tment, the Land Registry, the Immigrat ion Department , the Transpor t Depar tment, the In land Revenue Department , and the Companies Registry) or any other publ ic / pr ivate organisat ions ( inc luding but not l im ited to the Hong Kong Housing Soc iety) , to re lease your personal data to the HAD / ERO, so that the HAD / ERO can compare and cross check such data wi th those on the appl icat ion form when process ing th is appl icat ion and updat ing the voter regis trat ion and e lect ion-re lated records annual ly.

(15)This appl icat ion form must be s igned by the appl icant; o therwise, the HAD / ERO wi l l notprocess your appl icat ion.

(16)In addi t ion to sending wr i t ten registrat ion not ices after complet ion of process ing the appl icat ionfor change of regis tered part icu lars, the HAD / ERO wi l l not i f y e lectors by shor t message serv ice( i f the e lec tors have provided such information) that their appl icat ions for change of registeredpar t icu lars have been completed.

(17)These notes are for general guidance only. Appl icants should a lso refer to the RuralRepresentat ive Elect ion Ordinance (Cap. 576) , the Electora l Affa irs Commission Ordinance(Cap. 541) , the Elec t ions (Corrupt & I l legal Conduct) Ordinance (Cap. 554) and the subsidiarylegis lat ions made thereunder.

(18)For enquir ies on voter regist rat ion, p lease cal l 2152 1521 or wr i te to the HAD / ERO (Address:30/F, Southorn Centre, 130 Hennessy Road, Wan Chai , Hong Kong) .

Personal Information Collection Statement Purpose of Col lec t ion The personal data and other re lated informat ion provided by you by means of th is form (REF-1b) and the copy of ident i t y document you at tached ( i f appl icable) wi l l be used by the HAD / ERO for voter regis trat ion and e lect ion-re lated purposes. The provis ion of personal data and other re lated informat ion by means of th is form is vo luntary. However, i f you do not provide adequate and accurate data, the HAD / ERO may not be able to process your appl icat ion for registrat ion as an e lec tor. I f the ERO has determined that you are e l igib le to be registered as an e lector, your name and pr inc ipal res ident ia l address / correspondence address provided in th is form wi l l be compi led in a regis ter and made avai lable for publ ic inspect ion. I f necessary, the HAD / ERO may require a publ ic author i ty to furn ish your personal data for data matching when prepar ing a regis ter. Any person who uses the personal data provided in this form without the express consent of the data subject for any purpose other than the purposes s tated above may contravene the Personal Data (Pr ivacy) Ordinance (Cap. 486). Transfer of Informat ion The HAD / ERO may provide the informat ion suppl ied by you to other author ised departments / organisat ions / persons for the purposes of voter regis trat ion, e lect ion and a l l purposes re lated thereto under the re levant Ordinances and / or subsid iary legis lat ions. Access to Personal Data and Enquiry You have a r ight to request access to, and to request the correct ion of , the personal data and other re lated informat ion you suppl ied in accordance wi th the provis ions of the Personal Data (Pr ivacy) Ordinance (Cap. 486) . Such requests and enquir ies should be made in wr i t ing to the Elec tora l Registrat ion Off icer at 30/F, Southorn Centre, 130 Hennessy Road, Wan Chai , Hong Kong.