C - 监事的声明、承诺及确认（适用于在中华人民共和国（「中国」）注册成立的发行人）

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C - 监事的声明、承诺及确认（适用于在中华人民共和国（「中国」）注册成立的发行人）

过去的版本：有效期自 2015年04月01日至 2018年02月14日
查看其它版本请点击右侧的版本索引标签。

Part 1
第一部分

DECLARATION
声明

1

State:—
请填报：

(a)

present surname and any former surname(s)*
现时姓氏及任何前度姓氏*

(b)

alias, if any *
别名，如有*

(c)

present forename(s) and any former forename(s)*
现时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
国籍及前度国籍，如有

(g)

(i)	Hong Kong ID card number 香港身份证号码
(ii)	in the case of a non-Hong Kong ID cardholder, passport number or any identification document number and name of issuing authority 如为非香港身份证持有人，请列明护照号码或任何身份识别文件号码，以及签发机构名称

(h)

name of issuer (i.e. the new applicant/listed issuer)
发行人（新申请人╱上市发行人）名称

in English
英文

..............................

.............................

in Chinese
中文

..............................

.............................

...........................

	*	As set out in the Hong Kong ID card, or any relevant identification document referred to in 1(g) above
	*	香港身份证或上文1(g)所述的任何有关身份识别文件上所示者。

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 the Growth Enterprise Market of The Stock Exchange of Hong Kong Limited from time to time in force (the “GEM Listing Rules”) is:
按不时生效的《香港联合交易所有限公司创业板证券上市规则》（《创业板上市规则》）附录一A第41段或第17.50(2)条所述方式（视属何情况而定）载有本人个人资料的有关文件：

(Tick as appropriate)
(请在适当方格内加上√号）

In the case of new applicant:
如属新申请人：

□	the listing document dated......................which has been duly registered with the Companies Registry. 日期为 .................年.................. 月.................... 日并已正式在公司注册处登记的上市文件。

In the case of listed issuer:
如属上市发行人：

□	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. 发行人按《创业板上市规则》第17.50(2)条的规定，就委任本人为发行人监事的公告。公告日期为 ................年................ 月 ..................日。

Part 2
第二部分

UNDERTAKING AND ACKNOWLEDGEMENT
承诺及确认

The particulars referred to in this Part 2 are:—
此第二部分所述的资料为：

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...............................(填入发行人名字)监事的权力及职责时，本人（签署人）须：

(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; 尽力遵守不时生效的所有关于监事对中国或其他地方的公众公司的管辖、运作、行为或监管的责任、职责及义务的适用中国法律、规则、规例及规范声明；
(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 cause the issuer and its directors to act at all times in accordance with the issuer s articles of association; 尽力遵守发行人的公司章程的规定（包括有关监事职责的一切规定），并促使发行人及其董事在任何时候均按照发行人的公司章程而行事；
(c)	use my best endeavours to cause the issuer and its directors to comply with the Rules Governing the Listing of Securities on the Growth Enterprise Market of The Stock Exchange of Hong Kong Limited from time to time in force (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; 尽力促使发行人及其董事遵守不时生效的《香港联合交易所有限公司创业板证券上巿规则》（《创业板上巿规则》）、《公司收购及合并守则》、《公司股份回购守则》及香港所有其他不时生效的有关证券的法例及规例；
(d)	inform The Stock Exchange of Hong Kong Limited 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; 在本人担任发行人的监事的任何期间，如发行人的监事会对发行人的任何董事提出法律程序，立即通知及以书面通知香港联合交易所有限公司；
(e)	comply to the best of my ability, as if the same applied to me to the same extent as it does to directors of the issuer, 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; 尽力遵守下列条例及规则，犹如该条例适用于本人，程度上如同其适用于公司董事般：(a)《证券及期货条例》第XIVA及XV部；(b)《创业板上巿规则》第5.46至5.67条有关董事进行证券交易的规定；(c)《公司收购及合并守则》；(d)《公司股份回购守则》；以及(e)香港所有其他不时生效的有关证券法例与规例；
(f)	use my best endeavours to procure that any alternate of mine shall so comply; 尽力促使本人的任何替任人遵守上述各项；
(g)	I hereby give my irrevocable authority to the Executive Director of the Listing Division (as such term is defined in rule 1.01 of the GEM Listing Rules), or to any person uthorized by him, to disclose any of the foregoing particulars given by me to members of the GEM 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 Stock Exchange of Hong Kong Limited, to such other persons, as the said Executive Director of the Listing Division may from time to time think fit; and 本人兹授予上市科主管（按《创业板上市规则》第1.01条界定）（或获其授权的任何人士）不可撤回的权力，让他将本人提供的上述资料向创业板上巿委员会（按《创业板上市规则》第1.01条界定）委员披露；并在香港联合交易所有限公司主席或一位副主席批准的情况下，向上巿科主管不时认为适当的其他人士披露；及
(h)	I will, for so long as I remain a supervisor of the issuer and for the further period of 3 years from the date on which I cease to be a supervisor of the issuer, inform the Stock Exchange of Hong Kong Limited, by notice in writing to the Executive Director of the Listing Division,of any change to my residential address as set out in Part 1 of this Form as soon as reasonably practicable and in any event within 1 month of my so changing residence for the purpose of facilitating correspondence with the Exchange; and 在本人担任发行人监事期间及本人不再担任发行人监事之日起计三年内，如本人于本表格第一部分所填报的住址有任何更改，本人会在合理可行的情况下尽快而无论如何于本人更改住址后一个月内，以书面通告形式通知上市科主管，以便与交易所进行函件往来；及

2

I acknowledge and agree that:—
本人承认及同意：

(a)

a document or notice shall be deemed to have been served on me by The Stock Exchange of Hong Kong Limited:—
由香港联合交易所有限公司送交本人的文件或通告在以下情况被视作送达：

(i)	when it is served personally on me; or 专人送递予本人；或
(ii)	by sending a copy of it by post or by facsimile to me at my usual or last known residential or business address or at the address notified by me in Part 1 of this Form or at the address notified by me in accordance with paragraph 1 (h) of Part 2 of this Form; or 以邮递或传真方式送交本人的惯叙或最后为香港联合交易所所知的住宅或营业地址，或由本人于本表格第一部分通知的地址，或由本人根据本表格第二部分1(h)段通知的地址；或
(iii)	if there is a letter box for the address in question, by inserting through the letter box a copy of the document or notice enclosed in a sealed envelope addressed to me; 如有关地址设有信箱，把内附该文件或通告的密封信封（而信封上又注明是致本人的）投入信箱内；

(b)

the date of service shall be deemed to be the second business day (or, in the case of an overseas address, the tenth business day) after the date on which the copy was sent to or, as the case may be, inserted through the letter box for the address in question; and
上述文件或通告被寄往该地址或（视乎情况而定）被投入该地址的信箱内的日期后的第二个营业日（或如属海外地址，则第十个营业日）将被视为送达日期；及

(c)

as the case may be, in proving service it shall be sufficient to show that the envelope containing the notice was addressed to me at the address in question and had stamps or postage of sufficient value thereon to ensure that the same could be sent by post; and
要证明文件已被送达，只须证明载有该通告的信封乃寄致本人收启，且被寄往有关地址及贴有足够邮票或已付上足够邮资以确保可用邮递寄出；及

(d)

for the avoidance of doubt, in the event I change my residential or business address and fail to inform The Stock Exchange of Hong Kong Limited of any new address pursuant to paragraph 1 (h) of Part 2 of this Form, any document or notice served upon me at my former residential address or business address in accordance with this paragraph shall nevertheless be deemed to have been validly served upon me for all purposes.
为释疑起见，倘若本人更改本人的住宅或营业地址而并未根据本表格第二部分1(h)段通知香港联合交易所有限公司本人的新地址，则根据本段送往本人前度住址或营业地址的任何文件或通告，就各方面而言仍将被视作有效送达本人论。

I hereby submit to the jurisdiction of The Stock Exchange of Hong Kong Limited in respect of all matters relevant to the GEM Listing Rules.
本人在此接受香港联合交易所有限公司就有关《创业板上市规则》各方面的管辖。

I,.............................................................. [Insert Chinese name, if any]:
本人............................................................... [请填上中文姓名（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 Stock Exchange of Hong Kong Limited may rely upon the foregoing particulars in assessing my suitability to act as a supervisor of the issuer; and
谨以至诚郑重声明，在本C表格第一部分(1)及本C表格第一部分(2)所述文件所示有关本人的所有详细资料均为真实、完整及准确，且本人对上述资料的真实性、准确性及完整性承担责任，而本人亦无作出任何声明或遗漏，致使有关资料不真实或具误导性，本人亦明白在要项上提供虚假或具误导性的资料可能引致的后果（包括本表格附注所载内容）；本人并明白，香港联合交易所有限公司或会倚赖上述资料来评估本人是否适合出任发行人监事；及

(ii)

undertake and acknowledge with The Stock Exchange of Hong Kong Limited in the terms set out in Part 2 of this Form C.
按本C表格第二部分所载的条款向香港联合交易所有限公司作出承诺及确认。

Signature签署：....................................

Name of supervisor监事姓名：........................

Hong Kong ID Card Number*
香港身份证号码*：...................................

Dated日期：.

Certified as the true signature of..................................
由以下人士证明上述签署为....................... 的真实签署
By:

ignature (Secretary/Director)
签署（秘书╱董事）：...................................

Name (Secretary/Director)
姓名（秘书╱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.
如为非香港身份证持有人，请列明护照号码或任何身份识别文件号码，以及签发机构名称。

Note:
附注：

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.
按规定须呈交本表格的任何人士，若未能真实、完整及准确地填妥本Ｃ表格第一部分，或未能签立本Ｃ表格第二部分又或未能遵守该部分所作的任何承诺，均构成违反《创业板上市规则》。此外，凡提供本Ｃ表格所要求或所述资料的发行人监事均应注意，该等资料构成本意是为遵守「有关条文」（定义见香港法例第 571章《证券及期货条例》附表1第1部）项下关于提供资料的规定而向本交易所提供的资料，本交易所或会依赖该等资料。就此，　阁下应注意，根据《证券及期货条例》第384条，在要项上向本交易所提供虚假或具误导性的资料，有关人士即属犯法，会遭检控。若　阁下有任何疑问，应立即谘询本交易所或　阁下的专业顾问。