Form C Supervisor's Declaration, Undertaking and Acknowledgement (PRC Issuer)

Appendix 6
附錄六

DIRECTOR'S AND SUPERVISOR'S FORMS
董事及監事的表格

Form C

C表格

Supervisor's declaration and undertaking and acknowledgement in respect of an issuer incorporated in the People's Republic of China ("PRC")
監事的聲明、承諾及確認
(適用於在中華人民共和國(「中國」)註冊成立的發行人)

Part 1
第一部分

DECLARATION
聲明

1.
 
State:—
請填報:
in English
英文
in Chinese
中文
(a) present surname and any former surname(s)*
      現時姓氏及任何前度姓氏*
. . . . . . . . . . . . . .
(b) alias, if any*
      別名,如有*
. . . . . . . . . . . . . .
(c) present forename(s) and any former forename(s)*
      現時名字及任何前度名字*
. . . . . . . . . . . . . .
(d) date of birth
      出生日期
. . . . . . . . . . . . . .
(e) residential address
      住址
. . . . . . . . . . . . . .
(f) nationality and former nationality, if any
      國籍及前度國籍,如有
. . . . . . . . . . . . . .
(g)
(i) Hong Kong ID card number
香港身份證號碼
(ii) in the case of a non-Hong Kong ID cardholder, passport number or any identification document number and name of issuing authority
如為非香港身份證持有人,請列明護照號碼或任何身份識別文件號碼,以及簽發機構名稱
 


. . . . . . .


. . . . . . .
 


. . . . . . .


. . . . . . .
(h) name of issuer (i.e. the new applicant/listed issuer)
      發行人(新申請人╱上市發行人)名稱
. . . . . . . . . . . . . .


* As set out in the Hong Kong ID card, or any relevant identification document referred to in 1(g) above.
* 香港身份證或上文1(g)所述的任何有關身份識別文件上所示者。
2. The relevant document that sets out my personal details in the manner described in paragraph 41 of Appendix 1A or rule 17.50(2), as the case may be, of the Rules Governing the Listing of Securities on GEM of The Stock Exchange of Hong Kong Limited from time to time in force (the "GEM Listing Rules") is:
按不時生效的《香港聯合交易所有限公司GEM證券上市規則》(《GEM上市規則》)附錄一A第41段或第17.50(2)條所述方式(視屬何情況而定)載有本人個人資料的有關文件:

(Tick as appropriate)
(請在適當方格內加上√ 號)

In the case of new applicant:
如屬新申請人:
 
the listing document dated ........................... which has been duly registered with the Companies Registry.
日期為...........年...........月...........日並已正式在公司註冊處登記的上市文件。


In the case of listed issuer:
如屬上市發行人:
 
the announcement dated ........................... by the issuer as required under GEM Listing Rule 17.50(2) with regard to my appointment as a supervisor of the issuer.
發行人按《GEM上市規則》第17.50(2)條的規定,就委任本人為發行人監事的公告。公告日期為...........年...........月...........日。

Part 2
第二部分

UNDERTAKING AND ACKNOWLEDGEMENT
承諾及確認

The particulars referred to in this Part 2 are:—
此第二部分所述的資料為:

1. in the exercise of my powers and duties as a supervisor of ......................(Insert the name of the issuer) I, the undersigned, shall:
在行使......................(填入發行人名字)監事的權力及職責時,本人(簽署人)須:
(a) comply to the best of my ability with all applicable laws, rules, regulations and normative statements from time to time in force in the PRC relating to the responsibilities, duties and obligations of a supervisor in connection with the governing, operation, conduct or regulation of public companies in the PRC or elsewhere;
盡力遵守不時生效的所有關於監事對中國或其他地方的公眾公司的管轄、運作、行為或監管的責任、職責及義務的適用中國法律、規則、規例及規範聲明;
(b) comply to the best of my ability with the provisions of the issuer's articles of association (including all provisions regarding the duties of supervisors) and use my best endeavours to procure the issuer and its directors to act at all times in accordance with the issuer's articles of association;
盡力遵守發行人的公司章程的規定(包括有關監事職責的一切規定),並盡力促使發行人及其董事在任何時候均按照發行人的公司章程而行事;
(c) use my best endeavours to procure the issuer and its directors to comply with the GEM Listing Rules, the Code on Takeovers and Mergers, the Code on Share Buy-backs and all other relevant securities laws and regulations from time to time in force in Hong Kong;
盡力促使發行人及其董事遵守《GEM上巿規則》、《公司收購及合併守則》、《公司股份回購守則》及香港所有其他不時生效的有關證券的法例及規例;
(d) inform The Stock Exchange of Hong Kong Limited (the “Exchange”) forthwith and in writing, at any time while I am a supervisor of the issuer, of the initiation by the issuer's supervisory committee of legal proceedings against any director of the issuer;
在本人擔任發行人的監事的任何期間,如發行人的監事會對發行人的任何董事提出法律程序,立即通知及以書面通知香港聯合交易所有限公司(聯交所或本交易所);
(e) comply to the best of my ability, as if the same applied to me to the same extent as it does to directors, with: (a) Parts XIVA and XV of the Securities and Futures Ordinance; (b) rules 5.46 to 5.67 of the GEM Listing Rules relating to securities transactions by directors; (c) the Code on Takeovers and Mergers; (d) the Code on Share Buy-backs; and (e) all other relevant securities laws and regulations from time to time in force in Hong Kong;
盡力遵守下列條例及規則,猶如該條例適用於本人,程度上如同其適用於董事般:(a)《證券及期貨條例》第XIVA及XV部;(b)《GEM上巿規則》第5.46至5.67條有關董事進行證券交易的規定;(c)《公司收購及合併守則》;(d)《公司股份回購守則》;以及(e)香港所有其他不時生效的有關證券法例與規例;
(f) use my best endeavours to procure that any alternate of mine to comply with the provisions set out above;
盡力促使本人的任何替任人遵守上列條文;
(g) I, in accepting to be a supervisor of the issuer, hereby (i) irrevocably appoint the issuer as my agent, for so long as I remain a supervisor of the issuer, for receiving on my behalf any correspondence from and/or service of notices and other documents by the Exchange; and (ii) authorise the Executive Director - Listing Division (as such term is defined in rule 1.01 of the GEM Listing Rules), or any person authorised by the Executive Director - Listing Division, to disclose any of my personal particulars given by me to members of the Listing Committee (as such term is defined in rule 1.01 of the GEM Listing Rules) and, with the approval of the Chairman or a Deputy Chairman of the Exchange, to such other persons, as the Executive Director - Listing Division may from time to time think fit; and
本人接受出任發行人的監事,即(i)不可撤回地委任發行人為本人的代理人,在本人出任發行人監事期間,代表本人接收任何聯交所發出的信函及 / 或送達的通知書及其他文件,及(ii)授權上市科執行總監(按《GEM上市規則》第1.01條界定)(或獲其授權的任何人士)將本人提供的個人資料向上巿委員會(按《GEM上市規則》第1.01條界定)委員披露;並在聯交所主席或一位副主席批准的情況下,向上巿科執行總監不時認為適當的其他人士披露;及
(h) I shall inform the Exchange (in the manner prescribed by the Exchange from time to time):
本人須在下列情況下(以聯交所不時規定的方式)將下述資料通知聯交所:
(i) as soon as reasonably practicable after my appointment, my telephone number, mobile phone number, facsimile number (if available), email address (if available), residential address and contact address (if different from the residential address) for correspondence from and service of notices and other documents by the Exchange;
於獲委任後在合理可行情況下盡快提供本人的電話號碼、手機號碼、傳真號碼(如有)、電郵地址(如有)、住址及用以接收聯交所所發出的信函及送達的通知書和其他文件的聯絡地址(如與住址不同);
(ii) for so long as I remain a supervisor of the issuer, any change to the contact information as described in paragraph (i) as soon as reasonably practicable and in any event within 28 days of such change; and
在擔任發行人監事期間,如第(i)段所述聯絡資料有變,須在合理可行的情況下盡快(無論如何於有關變動出現後 28 日內)通知聯交所;及
(iii) for a period of 3 years from the date on which I cease to be a supervisor of the issuer, any change to the contact information as described in paragraph (i) as soon as reasonably practicable and in any event within 28 days of such change.
在本人不再擔任發行人監事之日起計三年內,如第(i)段所述聯絡資料有變,須在合理可行的情況下盡快(無論如何於有關變動出現後 28 日內)通知聯交所。
2. I acknowledge and agree that any correspondence from and/or service of notices and other documents by the Exchange to me when I am a supervisor of the issuer or after I cease to be so, for whatever purposes (including but not limited to the service of notice of disciplinary proceedings) shall be deemed to have been validly and adequately served on me when the document or notice is served personally or is sent by post, facsimile or email to the address or number I provide to the Exchange. I agree and acknowledge that I am responsible for keeping the Exchange informed of my up-to-date contact details. I acknowledge that, if I, as the supervisor or former supervisor of the issuer, fail to provide the Exchange with my up-to-date contact details or arrange for notices, documents or correspondence to be forwarded to me, I may not be alerted to any proceedings commenced against me by the Exchange.
本人承認及同意,在本人出任發行人監事期間或不再出任發行人監事之後,但凡聯交所就任何目的向本人發出的信函及 / 或送達的通知書及其他文件(包括但不限於送達紀律程序的通知)若以面交本人的方式,或以郵寄、傳真或電郵的方式送達本人向聯交所提供的地址或號碼,即已有效及充分地送達本人。本人同意及確認,本人有責任向聯交所提供本人最新的聯絡資料。本人確認,若本人(作為發行人的監事或前監事)未能向聯交所提供本人最新的聯絡資料,或未有為送呈本人的通知、文件或書信提供轉送安排,本人可能會不知悉聯交所向本人展開的任何程序。
3. I shall, when I am a supervisor of the issuer and after I cease to be so:
本人出任發行人監事時以及不再擔任發行人監事後均須:
(a) provide to the Exchange as soon as possible, or otherwise in accordance with time limits imposed by the Exchange:
盡快或根據聯交所設定的時限向聯交所提供以下資料及文件:
(i) any information and documents that the Exchange reasonably considers appropriate to protect investors or ensure the smooth operation of the market; and
聯交所合理地認為可保障投資者或確保市場運作暢順的任何資料及文件;及
(ii) any other information and documents or explanation that the Exchange may reasonably require for the purpose of verifying compliance with the GEM Listing Rules; and
聯交所可為核實是否有遵守《GEM上市規則》事宜而合理地要求的任何其他資料及文件或解釋;及
(b) cooperate in any investigation conducted by the Listing Division and/or the Listing Committee of the Exchange, including answering promptly and openly any questions addressed to me, promptly producing the originals or copies of any relevant documents and attending before any meeting or hearing at which I am requested to appear.
在聯交所上巿科及╱或上巿委員會所進行的任何調查中給予合作,包括及時及坦白地答覆向本人提出的任何問題,及時地提供任何有關文件的正本或副本,並出席本人被要求出席的任何會議或聽證會。
I hereby submit to the jurisdiction of the Exchange in respect of all matters relevant to the GEM Listing Rules.
本人在此接受聯交所就有關《GEM上市規則》各方面的管轄。

I,...........................[Insert Chinese name, if any]:
本人........................... [請填上中文姓名(如有)]:
(i) solemnly and sincerely declare that all particulars about me that appear in Part 1(1) of this Form C and in the document referred to in Part 1(2) of this Form C are true, complete and accurate, that I accept responsibility for the truthfulness, accuracy and completeness of the foregoing particulars, that I have not made any statements or omissions which would render such particulars untrue or misleading, that I understand the possible consequences of giving information which is false or misleading in a material particular including those as set forth in Note hereto, and that I understand that the Exchange may rely upon the foregoing particulars in assessing my suitability to act as a supervisor of the issuer; and
謹以至誠鄭重聲明,在本C表格第一部分(1)及本C表格第一部分(2)所述文件所示有關本人的所有詳細資料均為真實、完整及準確,且本人對上述資料的真實性、準確性及完整性承擔責任,而本人亦無作出任何聲明或遺漏,致使有關資料不真實或具誤導性,本人亦明白在要項上提供虛假或具誤導性的資料可能引致的後果(包括本表格附註所載內容);本人並明白,聯交所或會倚賴上述資料來評估本人是否適合出任發行人監事;及
(ii) undertake and acknowledge with the Exchange in the terms set out in Part 2 of this Form C.
按本C表格第二部分所載的條款向聯交所作出承諾及確認。
Signature 簽署: . . . . . . . . . . . . . . . . .

Name of supervisor 監事姓名: . . . . . . . . . . . .

Hong Kong ID Card Number*:
香港身份證號碼*: . . . . . . . . .

Dated 日期:. . . . . . . . . . . . . . . . . .

Certified as the true signature of . . . . . . . . .
由以下人士證明上述簽署為 . . . . . . . . . 的真實簽署

By:
Signature (Secretary/Director)
簽署(秘書╱董事):. . . . . . . . . . . . . .

Name (Secretary/Director)
姓名(秘書╱董事):. . . . . . . . . . . . .

* In the case of a non-Hong Kong ID cardholder, state the passport number or any identification document number and name of issuing authority.
如為非香港身份證持有人,請列明護照號碼或任何身份識別文件號碼,以及簽發機構名稱。

Note:
附註:

The failure of any person required to lodge this Form C to complete Part 1 of this Form C truthfully, completely and accurately or the failure to execute Part 2 of this Form C or to observe any of the undertakings made under that Part, constitutes a breach of the GEM Listing Rules. In addition, every supervisor of the issuer supplying information sought or referred to in this Form C, should note that such information constitutes information which is provided to the Exchange in purported compliance with a requirement to provide information under the "relevant provisions" (as defined in Part 1 of Schedule 1 to the Securities and Futures Ordinance, Cap. 571) and is likely to be relied upon by the Exchange. In relation to this, you should be aware that giving to the Exchange any information which is false or misleading in a material particular will render the relevant person liable for prosecution for an offence under section 384 of the Securities and Futures Ordinance. If you have any queries you should consult the Exchange or your professional adviser immediately.
按規定須呈交本表格的任何人士,若未能真實、完整及準確地填妥本C表格第一部分,或未能簽立本C表格第二部分又或未能遵守該部分所作的任何承諾,均構成違反《GEM上市規則》。此外,凡提供本C表格所要求或所述資料的發行人監事均應注意,該等資料構成本意是為遵守「有關條文」(定義見香港法例第 571章《證券及期貨條例》附表1第1部)項下關於提供資料的規定而向本交易所提供的資料,本交易所或會依賴該等資料。就此, 閣下應注意,根據《證券及期貨條例》第384條,在要項上向本交易所提供虛假或具誤導性的資料,有關人士即屬犯法,會遭檢控。若 閣下有任何疑問,應立即諮詢本交易所或 閣下的專業顧問。