Po Leung Kuk/Henrik Nielsen/Foreign Correspondents Club Scholarship Fund Scholarship for Tertiary/Higher Education Programmes

Transcription

1 Po Leung Kuk/Henrik Nielsen/Foreign Correspondents Club Scholarship Fund Scholarship for Tertiary/Higher Education Programmes * Delete whichever is inapplicable PERSONAL PARTICULARS (For Discharged Residential Children) *(PLK affiliated schools students / discharged residential children) 1. Name in full *Mr. / Miss: (as on Identity Card and in Block Capitals) (English Name) (Chinese) 2. Place of Birth: 3. Date of Birth: YYYY MM DD 4. Length of Residence in Hong Kong: years (from to ) 5. *Nationality/ Citizenship: 6. Hong Kong Identity Card Number: 7. Correspondence Address: (in Block Capitals) 8. Home Telephone No.: Day-time Contact Telephone No.: _ 9. Address: 10. Name of School and Class (20 /20 ) 11. Period Living in Po Leung Kuk Residential Child Care Unit (For Discharged Residential Children Only) From YYYY MM to YYYY MM Section: *Babies Section / Kinder Section / New Comers Ward / Emergency Foster Care / Children Section / Small Group Home (Please specify ) A recent photograph of the applicant to be affixed here SECTION A: FAMILY BACKGROUND Name of Father: Age: Address: Telephone No.: Occupation & Position Held: Name of Employer/Company: Company Address: Telephone No.: ************************************************************************************* Name of Mother: Age: Address: Telephone No.: Occupation & Position Held: Name of Employer/Company: Company Address: Telephone No.: Page 1

2 INCOME (Please submit supporting documents for verification) a. Yearly Income of Father $ Schools/Social (Including salary, MPF and other allowances) Workers Use Only b. Yearly Income of Mother $ (Including salary, MPF and other allowances) c. Other Incomes (1) Bonus $ (2) Commission $ (3) Rent from property $ (4) Year-end double-pay $ (5) Others $ d. Income from Other Family Members or $ Relatives (per year) Average Monthly Income per family members: a + b + c + d / No. of family members $ 12 Score (I) FAMILY MEMBERS This refers to members living together with the applicant. a. Sibling(s) receiving full-time education Name Date of Birth HKID Relationship No. Name of School Class Score b. Other Sibling(s) or Family Members Name Date of HKID Relationship Position Birth No. Held Yearly Income (salary + allowances) (II) Special conditions that are not mentioned above (e.g. family member suffering from chronic illnesses, disabled family member(s), widowed mother etc.) (III) _ (IV) _ Total Scores of _ Section A Page 2

3 SECTION B: ACADEMIC ACHIEVEMENT AND CONDUCT ACADEMIC ACHIEVEMENT a. HKCEE Results Year: Subject Chinese English Math Score Subject Schools/Social Workers Use Only b. HKAL Results Year: Subject Use of English Chinese Language and Culture Subject c. HKDSE Results Year: Subject English Subject Chinese d. Others (e.g. LCC examinations/ linguistics certificate course etc.) Year Name of Examination/ Qualifications Attained Total Scores of Section B Total Scores of Section A + B SECTION C: OTHER INFORMATION 1. For what degree/programme do you intend to study/are you studying locally? Degree/Programme: University: Subject or field of study: Special topic, if any, within the subject or field of study: Intended duration of study: years Expected commencement date of study: Page 3

4 2. Language proficiency a) List the language(s) (dialects) you speak (in order of competence) b) List the language(s) you read and write (in order of competence) 3. List the extra-curricular activities, community services and sports you have undertaken in recent years. (Include not more than five items which would provide strong support to your application) Activities Positions held/attainments Dates 4. Your proposed future occupation in Hong Kong. 5. Are you currently applying or intending to apply for any other scholarships or forms of financial assistance in relation to your proposed studies? Please give the names of the scholarships and results of your applications, if known. 6. Give a summary, in what ways awarding the Po Leung Kuk/Henrik Nielsen/Foreign Correspondents Club Scholarship Fund could change your life and/or serve the community. 7. Give any other information which you consider is relevant to this application. Page 4

5 8. For Discharged Residential Children: You are required to attach a typewritten statement together with the application on the personal history leading to the need of the scholarship and its likely impact on your personal life outlook. (Please write in English, in not more than 500 words) DECLARATION BY APPLICANT I, _ (name), declare that the statements made in this application are, to the best of my belief, true, complete and correct. I have read and fully understand the Information Note giving details of the scholarship which I am now applying for. Signature: _ Date: SECTION D: CONDUCT AND RECOMMENDATION (to be completed by principals/social workers) CONDUCT Previous Term This Term Conduct General Condition RECOMMENDATION Name: Dr. / Mr. / Ms.* Name of School / Residential Unit*: Position: Telephone No.: Recommendations: (Use separate sheets if necessary) Signature: _ Date: Page 5

6 Personal Information Collection Statement The personal data provided in the application forms for Po Leung Kuk/Henrik Nielsen/Foreign Correspondents Club Scholarship Fund will be used for scholarship application and other scholarship-related purposes. It may be provided to Po Leung Kuk Education Affairs Department (EAD) and other organisations or agencies authorised to process the information for purposes relating to scholarship released by Po Leung Kuk e.g. income assessment, academic achievement and conditional/straight offer by any Universities/Tertiary education provider, etc. as may be necessary. Your provision of all the personal data requested in the application forms for this scholarship is obligatory, except those items clearly marked as optional. Your application will not be considered if you fail to provide all information as requested or it is not clear from your statements that you have met the requirements specified for the scholarship. You are required to notify Po Leung Kuk EAD if there are any subsequent changes to the information provided after submission of the application form. Information on unsuccessful candidates will normally be destroyed 24 months after rejection of the candidate's application. For correction of or access to personal data after submission of the application form or enquiries on the scholarship matters, please contact the subject officer of EAD as specified in the application memo. Page 6