Annex B
Home Affairs Bureau
Multi-faceted Excellence Scholarship 2015-16
Application Form
Please affix a recent
colour photo here.
Instructions
(a) Applicants may complete this application form in either Chinese or English.
(b) Application forms should be either typewritten or written legibly in black ink.
(c) Please append additional sheets to this application form if necessary. Please write ‘Not Applicable
(N.A.)’ or ‘Nil’ for item(s) deemed appropriate.
(d) Documents and materials submitted with your application will not be returned.
(e) If you have referees other than your school principal and teachers, please ask them to fill in the Annex to
this Application Form.
(f) We may not be able to process your application if the information provided below is unclear, incorrect or
incomplete.
Section A - School Information
1. Name of school:
(Name in Chinese)
(Name in English)
2. Address:
3. Name of principal:
(
(Name in English)
4. Name of school contact person@:
)
(Name in Chinese)
(
(Name in English)
5. School telephone number:
6. School e-mail address#:
@ Please ensure that the contact person can normally be reached during school holidays.
# E-mails will be used as a major means of communication.
)
(Name in Chinese)
2
Section B - Personal Particulars
7. Applicant name:
(
(Name in English)
8. Age:
(Name in Chinese)
9. Date of birth:
11. Nationality:
)
10. Gender*:
Male/Female
12. Place of birth:
13. Hong Kong Identity Card/ Passport* number:
14. Home address:
15. Telephone number: (Home)
(Mobile)
16. Fax number:
17. E-mail address#:
Section C - Honours, Qualifications and Prizes Obtained
Note: Section C contains two parts: I. Major Area of Achievement, and II. Other Area of
Achievement.
Please complete I. Major Area of Achievement by selecting ONE area among 1. sports, 2.
arts/ music and 3. community services and enter a maximum of TWO items to illustrate
your achievements. E.g. Major area of achievement – sports; two items of achievement –
(i) Bronze medal, badminton men singles, the 2nd Summer Youth Olympic Games 2014, (ii)
Second Place Team, Inter-School Volleyball Competition 2012/13 (Hong Kong Island and
Kowloon), Division One, Boys B Grade.
Please complete II. Other Area of Achievement if you have achievements in an area apart
from the major area. Please enter a maximum of ONE item to illustrate your achievements
in this area. E.g. Other area of achievement – arts/music; one item of achievement – (i)
First Prize, Open Class, 2012 Hong Kong Music Competition for Young Pianists.
Remarks: Achievements in the science field, e.g. information technology and robot design,
are not considered to fall under the categories of sports, arts/ music or community
services.
* Please delete as appropriate.
# E-mails will be used as a major means of communication.
3
I. Major Area of Achievement
What is your major area of achievement? Please circle (select ONE only):
1. sports
2. arts/ music
3. community services
If your major area of achievement is sports or arts/ music, please complete Question 18. If
your major area of achievement is community services, please complete Question 19.
Please enter a maximum of TWO items.
18. Honours, qualifications and/ or prizes in the major area of achievement. (For each
competition, please provide the divisions/ sections, if applicable, and the number of
participants in the competition. Please also provide a copy of the certificate for each
item (if any).)
(i) Qualification/ prize:
Awarding body:
Year:
Division/ Section (if applicable):
Please list all divisions/ sections or age restriction under the competition (if applicable,
please specify from high to low) (e.g. Inter-School Swimming Competition – Division
One, Division Two, etc; Hong Kong International Music Festival Music Competition –
Youth Section, Junior Section, etc; All China Girls’ U16 Volleyball Championship –
age under 16 restricted.):
Number of competitors in your division/ section or number of competitors in your
competition:
Please briefly describe the qualification/ prize, its recognition and awarding criteria:
(ii) Qualification/ prize:
Awarding body:
Year:
Division/ Section (if applicable):
4
Please list all divisions/ sections or age restriction under the competition (if applicable,
please specify from high to low) (e.g. Inter-School Swimming Competition – Division
One, Division Two, etc; Hong Kong International Music Festival Music Competition –
Youth Section, Junior Section, etc; All China Girls’ U16 Volleyball Championship –
age under 16 restricted.):
Number of competitors in your division/ section or number of competitors in your
competition:
Please briefly describe the qualification/ prize, its recognition and awarding criteria:
19. Achievements in community service should be entered here.
(i) Name/ project title of the service programme:
Organiser:
Category and number of service beneficiaries:
Service history:
year(s), on average
hour(s) per year
Please briefly describe your role in the service programme and your contributions
made. For example, are you the founder of the programme? Have you taken up a
leadership role?
5
Did the service programme cover locations outside Hong Kong? If so, please specify
the locations and the duration.
Did the service programme involve any new element that is different from traditional
volunteering? If so, please elaborate.
Is there anything else regarding your service experience or the service programme that
you wish to mention?
6
Awards, prizes or recognition won (if any):
(ii) Name/ project title of the service programme:
Organiser:
Category and number of service beneficiaries:
Service history:
year(s), on average
hour(s) per year
Please briefly describe your role in the service programme and your contributions
made. For example, are you the founder of the programme? Have you taken up a
leadership role?
7
Did the service programme cover locations outside Hong Kong? If so, please specify
the locations and the duration.
Did the service programme involve any new element that is different from traditional
volunteering? If so, please elaborate.
8
Is there anything else regarding your service experience or the service programme that
you wish to mention?
Awards, prizes or recognition won (if any):
II. Other Area of Achievement
You may select at most ONE item on other area of achievement. Please circle (select ONE
only):
1. sports
2. arts/ music
3. community services
If your non-major area of achievement is sports or arts/ music, please complete Question
20. If your non-major area of achievement is community services, please complete
Question 21.
20. Honours, qualifications and/ or prizes in the non-major area of achievement (For each
competition, please provide the divisions/ sections, if applicable, and the number of
participants in the competition. Please also provide a copy of the certificate for each
item (if any).)
9
Qualification/ prize:
Awarding body:
Year:
Division/ Section (if applicable):
Please list all divisions/ sections or age restriction under the competition (if applicable,
please specify from high to low) (e.g. Inter-School Swimming Competition – Division
One, Division Two, etc; Hong Kong International Music Festival Music Competition –
Youth Section, Junior Section, etc; All China Girls’ U16 Volleyball Championship –
age under 16 restricted.):
Number of competitors in your division/ section or number of competitors in your
competition:
Please briefly describe the qualification/ prize, its recognition and awarding criteria:
21. Achievements in community service should be entered here.
(i)
Name/ project title of the service programme:
Organiser:
Category and number of service beneficiaries:
Service history:
year(s), on average
hour(s) per year
Please briefly describe your role in the service programme and your contributions
made. For example, are you the founder of the programme? Have you taken up a
leadership role?
10
Did the service programme cover locations outside Hong Kong? If so, please specify
the locations and the duration.
Did the service programme involve any new element that is different from traditional
volunteering? If so, please elaborate.
11
Is there anything else regarding your service experience or the service programme that
you wish to mention?
Awards, prizes or recognition won (if any):
Section D - Academic Results
[IMPORTANT: Please note that Question 22 is to be completed by the applicant, and
Question 23 is to be completed and signed by the school principal.]
22. Your Form 5 Final Examination Results. (To be completed by the applicant. Please
fill in all subjects taken, and attach a copy of your school certificate.)
1)
2)
3)
4)
5)
6)
7)
8)
Subject
Chinese Language
English Language
Mathematics
Liberal Studies
Result (in Grade)
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23. Expected HKDSE results of the applicant. (To be completed by the school principal.
Please fill in the subjects as provided in Question 22.)
1)
2)
3)
4)
5)
6)
7)
8)
Subject
Chinese Language
English Language
Mathematics
Liberal Studies
Result (in Grade)
Signature of school principal:
Name of school principal: (
)
Section E - Joint University Programmes Admissions System (JUPAS) Band A
Choices
[IMPORTANT: Please fill in your JUPAS Band A programme choices. You are free to
rearrange in the JUPAS system your Band A programme choices subsequent to the
application, but only the three programmes indicated here will be considered for
Scholarship selection. Selected candidates will only be awarded the Scholarship if they
are given conditional offer(s) by universities and/ or tertiary institutions, and if they are
eventually admitted to that particular programme.]
24. Please list below THREE programmes you intend to pursue. (Please attach the
curriculum description of the programmes.)
First Choice
(a) Name of institution:
(b) JUPAS Catalogue Number of programme:
(c) Full title of programme:
(d) Duration of programme:
Years
(e) Your justifications for this choice and priority:
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Second Choice
(a) Name of institution:
(b) JUPAS Catalogue Number of programme:
(c) Full title of programme:
(d) Duration of programme:
Years
(e) Your justifications for this choice and priority:
Third Choice
(a) Name of institution:
(b) JUPAS Catalogue Number of programme:
(c) Full title of programme:
(d) Duration of programme:
Years
(e) Your justifications for this choice and priority:
14
Section F - Non-JUPAS Choice
25. If you intend to apply for any non-JUPAS programme, please list below ONE choice.
This will be the only non-JUPAS programme considered for Scholarship selection. In
other words, selected candidates will only be awarded the Scholarship if they are
admitted to either one of the three JUPAS Band A programmes indicated above, or the
non-JUPAS programme indicated below. If you do not intend to apply for any
non-JUPAS choice, you can skip this question. (Please attach the curriculum
description of the programme.)
(a) Name of institution:
(b) Full title of programme:
(c) Duration of programme:
Years
(d) Your justifications for this choice:
Section G - Justifications on Nomination
[IMPORTANT: It is a mandatory requirement to provide justifications on the
nomination. Please note that Question 26 is to be completed by the applicant, and
Question 27 by the school principal.]
26. In 300 words, please explain why you consider yourself a deserving candidate for the
Scholarship. (To be completed by the applicant.)
15
27. In 300 words, please provide reasons for your nomination. (To be completed by the
school principal.)
16
Section H - Leadership
28. Have you taken up a leadership role in any of your achievements listed above (or in any
other bodies/ organisations)? If so, please specify in point form.
(E.g. Captain/ leader of a school team/ orchestra/ service organisation, President/
Chairperson of an Inter-school Student Body or Student Association/ Union, Head
Prefect, etc.)
17
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Section I - Notes on Handling of Information and Personal Data supplied in the
application form
This scholarship scheme is set up and operated by the Home Affairs Bureau of the
Government of the Hong Kong Special Administrative Region (“HAB”). The data in the
application form is supplied by the applicant voluntarily. The applicant may be asked to
provide additional information to help the HAB to process the application. If the applicant
does not provide sufficient information, the HAB may be unable to process the application
any further.
The personal data which the applicant provides in this application form will be retained by
the HAB for the purposes of processing this scholarship application, as well as compiling
relevant statistics and materials for publicity and review of the Scholarship. It may be
divulged to other organisations (including but not limited to the universities/ tertiary
institutions and the JUPAS Office) for the same purposes.
In submitting and signing this application form, the applicant authorises the HAB to
contact any organisations (including but not limited to the JUPAS Office) for the purpose
of obtaining or exchanging any information and for comparing or verifying the information
provided by the applicant with other information which the HAB may collect.
You are required to notify the HAB if there are any subsequent changes to the information
provided after submission of the application form (except any subsequent changes to the
JUPAS Band A choices, which you do not have to inform us).
The applicant has the right to request access to and/ or correction of personal data on this
form in accordance with the provisions of the Personal Data (Privacy) Ordinance. Such
requests may be made in writing to Executive Officer (1)11, 13/F, West Wing, Central
Government Offices, 2 Tim Mei Avenue, Tamar, Hong Kong.
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Section J - Declaration
I,
, solemnly and sincerely declare that the
(Name of Applicant)
information given in this application form is nothing but the truth and I understand that if I
wilfully give any false information or withhold any material information, my application
will be rejected. I further undertake to inform the Home Affairs Bureau of any significant
changes to the information in this application form, failing which may lead to my
application being disqualified. I have read and agreed to the notes at Section I concerning
the handling of information and personal data supplied in the application form.
Date:
Signature:
Signature of principal:
Name of principal :
Date :
[Note: The completed application form, together with all the required documents and
materials, should reach the Home Affairs Bureau at the following address by hand or
by post at or before 5:00 pm on 11 December 2015:
Home Affairs Bureau
13/F, West Wing, Central Government Offices
2 Tim Mei Avenue
Tamar
Hong Kong]
Enquiries may be directed to Mr Edward LAM at 3509 7001.
Home Affairs Bureau
September 2015
20
Annex
Home Affairs Bureau
Multi-faceted Excellence Scholarship 2015-16
Recommendation Form
Reference for
(Name of Applicant)
1.
How long and in what context have you known the applicant?
2.
In 300 words, please explain your reason(s) of recommendation (you may add a
separate sheet if necessary):
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Date:
Name:
Organisation:
Address:
Telephone no.:
E-mail address:
Signature:
Position: