Annex A

RESIDENTIAL CARE HOMES (ELDERLY PERSONS) ORDINANCE

APPLICATION FOR A LICENCE

Please read the note on page 7 and page 8 before submission.

Applicant must complete Sections I, II, III or IV, V(A) or V(B) and VI in English or Chinese. The
completed application form together with the required information and plans can be sent to LORCHE
by hand or by registered post. Should there be any changes to the information contained therein, the
applicant is required to inform LORCHE by written correspondence at the earliest possible time. The
hotline for enquiry of application for licence is 2961 7211 or 2834 7414.

Section I Please tick in the appropriate box

[ ] Application is hereby made for a Licence under Section 8(1) of the Residential Care
Homes (Elderly Persons) Ordinance.

[ ] Application is hereby made for a renewal of Licence under Section 9 of the

Residential Care Homes (Elderly Persons) Ordinance.

Existing Licence Number :

Section II Particulars of the residential care home for the elderly in respect of which
application for a Licence is sought.

(a) Name of the residential care home for the elderly in English :

(b) Name of the residential care home for the elderly in Chinese :

(c) Address of the residential care home for the elderly (state in detail the address which
should tally with the Business Registration Certificate, Business Registration
Application and Demand Note for Rate) :

Flat/Room Block Floor Name of Building

Number and Name of Street/Estate and/or Number of lot District

Hong Kong/Kowloon/New Territories *
SWD 603

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(d) Telephone number :

(e) Fax Number :

(f) Email Address (if applicable) :

(g) Number of floors of the building occupied by the residential care home for the
elderly : floor(s).

(h) Number of units of the building occupied by the residential care home for the
elderly : unit(s).

(i) Financing nature of the residential care home for the elderly : (Please tick as
appropriate)

[ ] Subvented

[ ] Self-financing and non-profit-making

[ ] Private

[ ] Contract Home

[ ] Others (please specify): ___________________________________

(j) Type of the residential care home for the elderly : (Please refer to Chapter 2 of the
Code of Practice for Residential Care Homes (Elderly Persons) for classification of
homes and tick as appropriate)

[ ] a care-and-attention home

[ ] an aged home

[ ] a self-care hostel

(k) The premises of the residential care home for the elderly is : (Please tick as
appropriate and provide documentary proof as stated in Note (b) (6) on page 8 below)

[ ] a self-owned property

[ ] a rented premises

[ ] partly self-owned and partly rented

- self-owned unit(s) concerned :

- rented unit(s) concerned :

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(l) Capacity versus occupancy of the residential care home for the elderly :

No. of Beds Existing No. of Residents

care-and-attention places

aged home places

self-care places

Total

(m) Net floor area of the residential care home for the elderly : (it should be the same
measurement marked on the layout plan submitted with this application form)

square meters

(n) The residential care home for the elderly is : (Please tick as appropriate)

[ ] a proposed service/business [ ] an existing service/business

(o) Date/Tentative date * of commencement of service/business :

Date Month Year

(p) Does the residential care home for the elderly comply with the lease conditions and
Deed of Mutual Covenant ? (Please refer to para. 4.2 under Chapter 4 of the Code of
Practice for Residential Care Homes (Elderly Persons) and tick as appropriate)

[ ] Yes [ ] No [ ] Others (please specify) : _____________

(q) Monthly fee charged per resident :

Minimum : $

Maximum : $

Section III Ownership of Business (For completion if the residential care home for the
elderly is a private establishment registered with the Inland Revenue
Department according to the Business Registration Ordinace)

(a) Ownership of business : (Please tick as appropriate)

[ ] Sole proprietorship

[ ] Partnership

[ ] Corporate body

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(b) Name of Owner(s) :

For completion if the ownership is sole proprietorship or partnership :

(i) Mr/Mrs/Miss/Ms *
(English, surname first) (Chinese)

Hong Kong Identity Card Number :

(ii) Mr/Mrs/Miss/Ms *
(English, surname first) (Chinese)

Hong Kong Identity Card Number :

(iii) Mr/Mrs/Miss/Ms *
(English, surname first) (Chinese)

Hong Kong Identity Card Number :

(iv) Mr/Mrs/Miss/Ms *
(English, surname first) (Chinese)

Hong Kong Identity Card Number :

(continue on separate sheet if necessary)

For completion if the ownership is a corporate body :

(i) Name of the Company in English :

(ii) Name of the Company in Chinese :

Section IV Particulars of the Non-government Organization (For completion if the

residential care home for the elderly is a subvented or self-financing
non-profit-making establishment)

(a) Name of the Organization in English :

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(b) Name of the Organization in Chinese :

Section V(A) Particulars to be completed by the applicant if the applicant is an individual

(see Note (a))

(a) Full name of the applicant in English (must be the same as shown on HKIC) :

Mr/Mrs/Miss/Ms*
Surname first, then other names

(b) Full name of the applicant in Chinese characters (must be the same as shown on
HKIC) :

(c) Hong Kong Identity Card Number :

(d) Residential address :

Flat/Room Block Floor Name of Building

Number and Name of Street/Estate District

Hong Kong/Kowloon/New Territories *

(e) Correspondence address (if different from (d) above) :

Flat/Room Block Floor Name of Building

Number and Name of Street/Estate District

Hong Kong/Kowloon/New Territories *

(f) Telephone number : (Residence)

(Office)

I select the residential address □ ／

correspondence address □ as the address
to be indicated in the Licence (Item 3(b) refers).

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(g) Position held by the applicant in the residential care home for the elderly : (if
applicable)

Section V(B) Particulars to be completed by the applicant if the applicant is a corporate

body/ non-government organization *

(a) Name of the Company/Non-government Organization * in English :

(b) Name of the Company/Non-government Organization * in Chinese :

(c) Business Registration Number (if applicable) :

(d) Certificate of Incorporation Number (if applicable) :

(e) Address of the Company/Non-government Organization * :

Flat/Room Block Floor Name of Building

Number and Name of Street/Estate District

Hong Kong/Kowloon/New Territories *

(f) Telephone Number :

(g) Name of Responsible Person of the Company/Non-government Organization* :

Mr/Mrs/Miss/Ms *
(English, surname first) (Chinese)

(h) Position held in the Company/Non-government Organization* :

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Section VI Declaration of applicant

I declare that :

(a) the information in this application is true and correct to the best of my knowledge and
belief; and

(b) the operation, keeping, management or other control of the residential care home for
the elderly referred to Section II above is under my continuous and personal
supervision.

Date : Signature of applicant :

Company/Organization chop* (if applicable) :

* Delete as appropriate

Note: (a) Individual(s) means natural person(s)

(b) The applicant should forward the following documents to the Licensing Office
of Residential Care Homes for the Elderly(LORCHE), Social Welfare
Department at :

Room 2354, 23/F Wu Chung House

213 Queen's Road East
Wan Chai
Hong Kong

(1) the original and three copies of this application form

(2) photocopy of the Hong Kong Identity Card of the applicant (applicable
if application is made by an individual)

(3) certified copy of Business Registration Application and photocopy of

the Business Registration Certificate from the Commissioner of Inland
Revenue (applicable for private residential care home for the elderly)

(4) photocopy of Certificate of Incorporation issued by the Registrar of

Companies (applicable if application is made by a corporate body)

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 (5) seven copies of layout plans of the premises of the residential care
home for the elderly in metric and to scale (not less than 1:100 and
details in the Guidance Notes on Submission of Floor Plans) for new
application (equally applicable to renewal of licence only if there are
changes in home layout)

(6) documents to verify authenticity of the address of the proposed home,

e.g. the deed of assignment (for self-owned premises), tenancy
agreement (for rented premises) or utility bills such as water supply or
electricity

(7) a. for RCHE located in a non-domestic building or non-domestic

part of a composite building, ‘No objection’ letter issued by the
Buildings Department in respect of the intended ‘Change in
use’

b. for a RCHE located in a building defined as the New

Territorries Exempted House (NTEH), written agreement from
the Lands Department to the use of the subject premises for
residential care home purpose

(8) full list of staff employed/to be employed with the following

information by using the Staff Employment Record :

a. name of staff in both English and Chinese

b. Hong Kong Identity Card Number

c. sex and age

d. post held at the residential care home for the elderly

e. working hours

f. date of commencement of current employment

WARNING :

Any person who in or in connection with this application makes any statement or furnishes
information whether such statement be oral or written, which is false in any material
particular and which he or she knows or reasonably ought to know is false in such particular
shall be guilty of an offence under Section 21(6)(a) of the Residential Care Homes (Elderly
Persons) Ordinance. The supply of such false information may also prejudice the
application and an existing licence.

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