禁毒基金资助药物倚赖者治疗康复中心特别拨款计划申请表.doc

/sundae_meng本欄無須填寫For Official Use Only檔案編號Reference No:禁毒基金资助药物倚赖者治疗康复中心特别拨款计划申请表Beat Drugs Fund Special Funding Scheme for Drug Dependent Persons Treatment and Rehabilitation CentresApplication Form申请机构必须参阅禁毒基金资助药物倚赖者治疗康复中心特别拨款计划手册（手册），并于手册指定的截止日期以前（如适用）送交香港金钟道66号金钟政府合署高座30楼禁毒基金会(由禁毒处转交)。This form should be completed with reference to the “Manual of Beat Drugs Fund Special Funding Scheme for Drug Dependent Persons Treatment and Rehabilitation Centres” (the Manual). It should be returned to the Beat Drugs Fund Association, c/o Narcotics Division, 30/F, High Block, Queensway Government Offices, 66 Queensway, Hong Kong before the deadline stipulated in the Manual (if applicable).(可用中文或英文填写。This form can be completed in Chinese or English)I. 计划名称 Project Name中文Chinese: _英文English: _II. 申请机构 Name of applicant 中文Chinese: _英文 English: _地址Address: _电话:传真:电邮地址:Tel. No. _Fax No. _E-mail address _负责人: 职衔:Responsible Person: _Post Title: 可提供更详尽数据的人士 (如与上述填报的负责人不同)Person to be contacted for further information (if different from the responsible person)姓名 :职衔 :Name _Post Title _地址 :Address _电邮地址 E-mail address _电话: 传真: Tel No. _Fax: _ III. 申请机构背景 Background Information of Applicant(i) 请注明是否根据下列条例注册:Please state whether it is registered under - 社团条例 公司条例the Societies Ordinancethe Companies Ordinance 其他 (请注明) Others (please specify) _注册年份 (Year of Registration: _)(ii) 请注明是否税务条例第88条所指的慈善机构: Please state whether the applicant is a charitable organization for the purpose of section 88 of the Inland Revenue Ordinance - 否 是 (请提供由税务局发出的IR表格第302号)No Yes (please provide Form 302 issued by the Inland Revenue Department)(iii) 治疗中心的性质 Nature of the treatment centre 津贴Subvented 自负盈亏及非牟利 Self-financing and non-profit-making (iv) 治疗中心可收纳的药物倚赖者名额Capacity of the treatment centre for drug dependent persons _(v) 治疗中心过去三年入住的药物倚赖者人数No. of drug dependent persons residing in the centre in the past three years年 入住人数Year No. of residents (vi) 过去三年入住中心药物倚赖者服务使用率Rate of placement occupancy of the drug dependent persons residing in the centre in the past three years年 服务使用率Year Placement occupancy (vii)(a)治疗中心过去三年完成戒毒治疗及康复课程，并于离开中心一年内不复吸的药物倚赖者人数No. of patients who completed the drug treatment and rehabilitation program and is abstinent from drugs for one year after discharge from the centre in the past three years年 人数 Year No of patients(b)在过去三年每年在治疗中心完成戒毒治疗及康复课程的人数No. of dischargees from the centre every year in the past three years年 人数 Year No of patients IV. (i) 计划预计开始时间Expected Start Date of Project: _(日/月/年) (Day/Month/Year)(ii)计划进行年期Project Duration: _(iii)计划预计完成时间Expected Completion Date: _(日/月/年) (Day/Month/Year)V. 财政预算Budget(i) 申请拨款总额Total Grant Sought: $_(ii) 其他已获/正申请的赞助Any other sponsorship sought / being sought 没有 有No Yes资助来源Source of Fund Applied已获得/正申请的资助Amount Received*/Requested申请进展Progress of Application(如申请已被书面拒绝，请附上证明文件Please attach reject letter as documentary support of the application is unsuccessful)VI.计划详情 Project Details (i) Category类别Amount requested$申请款额元Attachment(please tick where appropriate)附件(请在适当方格内加号)Works item for construction / fitting out / renovation / conversion / expansion / reprovisioning / improvement建筑 / 装修/ 翻新/ 改建/ 重建及改善工程等工程项目()Annex附件Aand Annex 及附件B ABFurniture & equipment 家俬及用具()Annex附件CCOthers (please specify)其他 (请注明)()Total :总款额 :() (ii) 请另页书写下列所需资料: Please use separate sheets for the following items:详细说明计划的To explain details of project ona) 背景backgroundb) 目标 objectivesc) 受惠对象及预期人数targets and expected number of beneficiariesd) 工程的详情details of workse) 进度表action plan with time-linef) 预算，应按年度详列各项开支项目budget, with detailed breakdown of the cost of expenditure items for each financial yearg) 申请人/机构如何就推行计划作准备；及readiness of the applicant for undertaking the project; andh) 申请人/机构是否具备其他有利推行计划的因素/设施whether the applicant possesses other favourable factors or anyfacilities for implementing the projectVII.政府部门的批准情况Approval from Government Departments(i)请说明中心所涉及土地的使用权类别 (例如政府土地牌照，批地契约、短期租约或短期豁免书等)及有关届满日期。Please state the land status of the centre (e.g. Government Land Licence, Land Lease, Short Term Tenancy or Short Term Waiver, etc.) and the expiry dates for its use._(ii)请说明拟进行工程是否已获政府批准 (包括契约修订，根据牌照或契约条款所发出的批准书，及根据建筑物条例 (新界适用) 修例 【香港法例第一二一章】所发出的豁免证明书或根据建筑物条例【香港法例第一二三章】对有关建筑图则的核准等，及符合土地的规划用途。)Please state whether necessary approvals have been obtained from Government for the proposed building works (including lease modification, approval under license or lease conditions and Certificates of Exemption under the Buildings Ordinance (Application to the New Territories) Ordinance, Cap. 121, or approval of plans under the Building Ordinance, Cap. 123 and, compliance with land use zoning). 地政处 District Lands Office 已获地政处批准(请提供证明文件) approved by District Lands Office (please provide supporting documents) 已向地政处申请,但仍待审批(请提供证明文件) have applied to District Lands Office and the approval is awaited (please provide supporting documents) 无需向地政处申请approval from District Lands Office not required屋宇署 Buildings Department 已获屋宇署批准(请提供证明文件) approved by Buildings Department (please provide supporting documents) 已向屋宇署申请,但仍待审批(请提供证明文件) approval from Buildings Department is awaited (please provide supporting documents) 无需向屋宇署申请approval from Buildings Department not required 申请其他部门批准情况(请另页书写详情)Progress in obtaining approvals from other Government departments(please provide details on separate sheets)_(iii)请说明是否备有证明文件，例如承建商或建筑商所提供的报价单、图则草图和照片。Please state whether supporting documents such as quotations from contractors/architects, plans, sketch maps and photographs are available. 否 No 是 (请注明文件类别及夹附有关文件) Yes (Please specify the types of documents available and enclose them )(iv)如计划涉及兴建新的建筑物，请说明建筑图则是否已获有关当局批准。If the proposed project involves construction of new buildings, please state whether the relevant building plans have been approved by the authorities concerned. 否 No 是 (请夹附证明文件) Yes (Please enclose supporting documents) 不适用 Not applicableAnnex ASummary of the Application for Works Items for Construction/ Fitting-out/ Renovation/ Conversion/ Expansion/ Re-provisioning/ Improvement申请建筑/ 装修/ 翻新/ 改建/ 扩建/ 重建及改善工程等工程项目拨款摘要Item No.项目Summary of Items Requested工程项目摘要Amount ($)款额 (元)Remarks备注1.Works Items工程项目类别1.1Concrete Works混凝土工程1.2Brickwork & Blockwork砖工1.3Carpentry & Joinery (including Ironmongery)木工及细木工 (包括木工五金配件)1.4Metal Works铁器工程1.5Plastering & Finishes水泥批荡及饰面工程1.6Plumbing & Drainage供水及排污装置工程1.7Glazing玻璃装嵌工程1.8Painting油漆及涂饰工程1.9Electrical Works电气设备装置工程1.10Heating, Ventilation & Air-conditioning Works暖气，通风与空气调节设备装置工程1.11Fire Services Installation消防设备装置工程1.12Gas Installation气体设备装置工程1.13Others (please specify)其他 (请注明)Sub-total分项1 合计款额2.Professional Fees and Related Contractual Charges顾问及有关工程合约支出 2.1Preliminaries基本工程合约条款支出 / 初步费用2.2Professional Fees认可人 / 专业顾问费Sub-total分项2 合计款额GRAND TOTAL总款额Annex BBreakdown and Details of the Proposed Works Items建造工程细项详细阐释Item No.项目编号Detail Location and Extent of Works of the Works Items各项工程之详细位置及范围Quantity数量Unit单位Unit Rate单价Amount ($)款额(元)Justification/ Remarks (provide in separate sheet if necessary)理据 / 备注 (可另纸呈报)Total总款额Note:Please provide prerequisite documents (e.g. approval of the landlord/ authority concerned, recommendation from Government departments concerned, sketches, drawings, layout plans, installation plans, quotations, specifying material & works method, etc).注:请提交各项施工所需的文件以供审阅 (文件包括有关业主 / 授权机构的核准书，有关政府部门的推荐信，工程草图，图则，分布图，装备系统图，报价单，指定物料，施工方法等)Annex CBreakdown and Details for Furniture and Equipment Items家俬及用具项目Item No.项目编号Detail of Items and Locations项目详情及位置Quantity and Unit数量及单位Unit Rate单价Amount ($)款额(元)Justification (please state whether it is a new item, replacement or improvement item; and with elaboration)理据 (请说明该项目是新项目，更新或改善项目；并加以详述)Total总款额# 谨此证明，据本人/我们*所知，申请表内所填报的数据均正确无讹。本人/我们*同意，如拟议计划获禁毒基金会批准，表格内所提供的数据对申请人/机构具有约束力。本人/我们*又保证，如日后本人/我们*向其他方面申请资助同一计划，定必通知禁毒基金会秘书。I/We* certify that the information given in this Application Form is correct according to the best of my/our* knowledge. I/We agree that the information provided in this application would be binding on the applicant if the proposed project is approved by the Beat Drugs Fund Association. I/We* also undertake to inform the Secretary, Beat Drugs Fund Association if, subsequent to this application, I/We* apply for funds from other sources for the same project.签署Signature:职衔Post title:姓名Name:日期Date:机构盖章Official Chop*删去不适用者 delete where appropriate有关收集个人资料声明Personal Information Collection Statement收集目的Purpose of Collection1.这份表格内填报的个人资料，是供禁毒基金会及其秘书处，用来审批此项拨款计划之用。The personal data provided in relation to this application will be used by the Beat Drugs Fund Association and its Secretariat for the purpose of assessing applications to this Funding Scheme. 2.在这份表格填报个人资料纯属自愿性质。如未能提供某些数据，可能会影响申请书的评审。The provision of personal data in relation to this application is voluntary. However, please note that the absence of certain information may affect the assessment of the application.披露资料Classes of Transferees3.为了审批此项拨款计划的申请，禁毒基金会可能会把这份表格所载的个人资料，向禁毒处、其他政府部门、外聘评审员、监察员，及其他有关人士披露。The personal data you provide by means of this application may be disclosed by the Narcotics Divi