Yang Dental Clinic F-YLG802(1) - E

＜Form for public use＞

Application form for Data Subject to access / obtain information (For the purpose of accessing / obtaining personal data only)

Please read the section of ‘notes’ at the end of the form carefully before filling in this application form.

Part One Details of the data subject who request to access his or her personal data

(a) Name： (b) Sex：male / female*

(c) Date of birth: year month day (d) Age： years old (e) Identity card/ passport * number：

(f) Birth certificate number (applicable for non-adults who do not have HKID cards or passport):

(g) Address ：

(h) Daytime contact telephone number：

(i) Mobile phone /other telephone number：

Part Two

The relevant person who submits application on behalf of the data subject to access the personal data should fill in this part

(1) Details of the relevant person

(a) Name： (b) Sex：male /female *

(c) Date of birth : year month day (d) Age： years old

(e) Identity card/ passport * number：

*please delete the inappropriate

Established：12.2000 Revised：12.2015 Implement：12.2015 Review：1.2021 P.1 Yang Dental Clinic F-YLG802(1) - E (f ) Address ：

(g) Daytime contact telephone number：

(h) Mobile Phone /other telephone number：

(2) Please specify the relationship between the relevant person and the data subject. Please put a「 」 on the box and submit the written documentation as evidence stated at the right-handed column.

Relationship Written documentation needed

The relevant person is:

 Parents/guardian of the data One certified true copy which proves subject (if the data subject is less the relationship between the two than 18 years old) parties (such as the birth certificate of the data subject)

 Person who is authorized by One certified true copy of the Court to handle affairs for documentation issued from the Court the data subject (e.g. the data authorizing that person subject is not capable to handle affairs by himself or herself)

 Person who is authorized by the Original copy of the authorization data subject via written letter duly signed by the data subject. authorization to make request on The name and the identity certificate his or her behalf number should be stated clearly in the authorization letter (such information must be identical to the identity certification submitted together with this application form.)

Established：12.2000 Revised：12.2015 Implement：12.2015 Review：1.2021 P.2 Yang Dental Clinic F-YLG802(1) - E

Part Three

(1) Details of the request for the personal information of the data subject

Please state clearly the details of your request for personal information: for example, the period, types of records, file number and the name of the service unit which possesses relevant information. That service unit can be either the unit which collected the personal information of the data subject, the one which the data subject apply to use its service.

Please attach another sheet if space is not sufficient enough. If further information to locate the related personal information is needed, our staff members will contact you shortly.

(2) Nature of your request Please put a 「」at the appropriate box (you can choose to tick both simultaneously):

 I hope to know if your Agency possesses the personal information of the data subject mentioned in Part Three (1)

 If your Agency possesses the personal information mentioned in Part Three (1), I hope that your Agency can provide me with a copy. I understand that I have to pay for the copying fee and your Agency shall inform me the amount of payment shortly; I can decide if I need this copy after I received your notification.

Signature of the data subject Signature of the relevant person (if any)

Date Date

Notes：

Established：12.2000 Revised：12.2015 Implement：12.2015 Review：1.2021 P.3 Yang Dental Clinic F-YLG802(1) - E (1) According to the ＜Personal Data (Privacy) Ordinance＞, the data subject (meaning the individual of the personal information)，could request for accessing and correction of personal data to data user. However, under certain circumstances, the data user could refuse to entertain the request of data subject according to the provision of the Ordinance and the related exemption clause. If a data subject requests a copy of his or her personal data, he or she has to pay the required fee. That data subject could ask the relevant person defined by the Ordinance to make request on his/ her behalf to collect the personal information.

(2) The information filled in the application form would be used for processing the request of accessing of the personal information. The information is provided to our Agency on voluntary basis. If you do not provide sufficient personal information, our Agency may not be able to handle your application. Please ensure the information you provided is correct and accurate. Note that you need to fill in the “Application form for correcting personal data” if you need to correct your personal information.

(3) Please submit the following document together with this application form：

(a) if the applicant is the data subject himself/herself One certified true copy of the Hong Kong Identity Card, Passport or Birth Certificate of the applicant.

(b) if the applicant is the relevant person (i) One certified true copy of the Hong Kong Identity Cards, Passports or Birth Certificates of both the data subject and the relevant party respectively; and (ii) The documentation required in the Part Two (2).

(4) The personal information you provided would be used by relevant staff members who must know such data in order to proceed on related working procedure. Moreover, the staff members of our Agency, if necessary, will only disclose your personal data to the following related parties:-

a) Other parties who are related to and involve assessments of your application or parties including governmental policy-making bodies/ departments and non- governmental organizations which provide services/ support to you; or b) Parties or other concerned parties to which you have consented to disclose your personal data; or c) Parties or other concerned parties to which you are stipulated or authorized by law to disclose your personal data.

(5) For any inquiries concerning the application form of collecting personal information, including access to and correction of personal data, please contact our Administrative Officer at 2251 0888. Address: 54 Waterloo Road, Kowloon, Hong Kong

Established：12.2000 Revised：12.2015 Implement：12.2015 Review：1.2021 P.4