Annex C
Home Affairs Bureau
Scholarship Scheme to Promote Multi-faceted Excellence 2015-2016
Application Form
Please affix a recent
photo.
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) which you deem appropriate.
(d) Documents and materials submitted with your application will not be returned.
(e) If you have reference by other nominator(s), please fill in the Annex which is attached to this Application
Form.
Section A - School Information
1. Name of school:
(Name in Chinese)
(Name in English)
2. Address:
3. Name of Principal:
(
(Name in English)
)
(Name in Chinese)
4. School Telephone number:
Section B - Personal Particulars
5. Name:
(
(Name in English)
6. Age
7. Date of birth
9. Nationality
10. Hong Kong Identity Card/Passport number*
* Please delete as appropriate.
)
(Name in Chinese)
8. Place of birth
2
11. Home address
12. Telephone number (Home)
(Mobile)
13. Fax number
14. 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. For Major Area of Achievement, please select ONE area among 1. sports,
2. arts/music and 3. community services, and enter a maximum of TWO items in part I
below. If you also have achievements in another area other than the major area, please
enter a maximum of ONE item in part II below.
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 15. If
your major area of achievement is community services, please complete Question 16.
Please enter a maximum of TWO items.
15. 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):
Number and details of Division/Section in the competition (if applicable):
Number of competitors in your Division/Section or number of competitors in your
competition:
3
Please briefly describe the qualification/prize:
(ii) Qualification/prize:
Awarding body:
Year:
Division/Section (if applicable):
Number and details of Division/Section in the competition (if applicable):
Number of competitors in your Division/Section or number of competitors in your
competition:
Please briefly describe the qualification/prize:
16. Items on community services should be entered in this question.
(i) Name/project title of the service:
Organiser:
Service Beneficiaries:
Service History:
Year(s), on average
Hour(s) per year
Is the volunteering work on your own initiative? Have you taken up a leadership role
in the bodies? If yes please specify.
4
Is the service covering areas outside Hong Kong? If so, please specify the areas and
the duration.
Does the service involve new concepts/innovative services different from
traditional/common volunteer services? If so, please elaborate on the service and
specify the duration.
Any special circumstances during the provision of services warranting special
mention?
5
Awards/prizes or outside recognition won (if any):
Please briefly describe your role, contribution made via and the values of the
community services.
(ii) Name/project title of the service:
Organiser:
Service Beneficiaries:
Service History:
Year(s), on average
Hour(s) per year
Is the volunteering work on your own initiative? Have you taken up a leadership role
in the bodies? If yes please specify.
6
Is the service covering areas outside Hong Kong? If so, please specify the areas and
the duration.
Does the service involve new concepts/innovative services different from
traditional/common volunteer services? If so, please elaborate on the service and
specify the duration.
Any special circumstances during the provision of services warranting special
mention?
Awards/prizes or outside recognition won (if any):
7
Please briefly describe your role, contribution made via and the values of the
community services.
II. Other Areas of Achievement
You may enter 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
17. If your non-major area of achievement is community services, please complete
Question 18.
17. 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).)
Qualification/prize:
Awarding body:
Year:
Division/Section (if applicable):
Number and details of Division/Section in the competition (if applicable):
8
Number of competitors in your Division/Section or number of competitors in your
competition:
Please briefly describe the qualification/prize:
18. Items on community services should be entered in this question.
Name/project title of the service:
Organiser:
Service Beneficiaries:
Service History:
Year(s), on average
Hour(s) per year
Is the volunteering work on your own initiative? Have you taken up a leadership role
in the bodies? If yes please specify .
Is the service covering areas outside Hong Kong? If so, please specify the areas and
the duration.
9
Does the service involve new concepts/innovative services different from
traditional/common volunteer services? If so, please elaborate on the service and
specify the duration.
Any special circumstances during the provision of services warranting special
mention?
Awards/prizes or outside recognition won (if any):
Please briefly describe your role, contribution made via and the values of the
community services.
10
Section D - Academic Results
[IMPORTANT : Please note that Question 19 is to be completed by the applicant, and
Question 20 by the school principal.]
19. Your Form 5 Final Examination Results (To be completed by the applicant. Please fill
in all subjects taken, and attach a copy of the certificate for your results.)
1)
2)
3)
4)
5)
6)
7)
8)
Subject
Chinese Language
English Language
Mathematics
Liberal Studies
Result (in Grade)
20. Expected HKDSE results of the applicant (To be completed by the school principal.
Please fill in the six subjects as provided in Question 19.)
1)
2)
3)
4)
5)
6)
7)
8)
Subject
Chinese Language
English Language
Mathematics
Liberal Studies
Result (in Grade)
Signature of School Principal:
(
)
11
Section E - JUPAS Band A Choices
[IMPORTANT : Please fill in your JUPAS Band A programme choices. Please attach a
copy of the page of JUPAS system showing your Band A choices.]
21. Please list below THREE choices of your intended courses and institutions. (Please
attach a copy of the curriculum description of your intended courses.)
First Choice
(a) Name of institution
(b) Programme JUPAS Catalogue number
(c) Programme full title
(d) Duration of Programme
Years
(e) Your justification of this choice and priority
Second Choice
(a) Name of institution
(b) Programme JUPAS Catalogue number
(c) Programme full title
(d) Duration of Programme
Years
(e) Your justification of this choice and priority
12
Third Choice
(a) Name of institution
(b) Programme JUPAS Catalogue number
(c) Programme full title
(d) Duration of Programme
Years
(e) Your justification of this choice and priority
Section F - Non-JUPAS Choice
22. Please list below ONE choice of your intended course and institution. If you do not
intend to apply for any non-JUPAS choice, you can skip this question. (Please attach a
copy of the curriculum description of your intended course.)
(a) Name of institution
(b) Programme full title
(c) Duration of Programme
Years
(d) Your justification of this choice
Section G - Justifications on Nomination
[IMPORTANT : It is a mandatory requirement to provide justifications on the
nomination. Please note that Question 23 is to be completed by the applicant, and
Question 24 by the School Principal.]
13
23. Please explain why you consider yourself a deserving candidate for the scholarship?
(To be completed by the applicant)
14
24. Please provide reasons for your nomination. (To be completed by the School Principal)
15
Section H - Leadership
25. Have you taken up a leadership role in any of your achievements listed above (or any
other bodies/organizations)? If so please specify.
(E.g. Captain/leader of a school team/orchestra/organization, President/Chairperson
of an Inter-school Student Body or Student Association/Union, Head Prefect etc.)
16
26. 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 by means of this application form will be
retained by the HAB for the purpose of processing this application for scholarships and the
compilation of the relevant statistics and materials for publicity and review of the
scholarships. It may be divulged to other organisations (including but not limited to the
universities and the Joint University Programmes Admissions System (JUPAS)) 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 JUPAS) 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.
17
Section I - 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 item 26 concerning
handling of information and personal data supplied in the application form.
Date
Signature
Signature of Principal
Name of Principal
Date
[Note: Completed application form, together with all the required documents and
materials, should reach the Home Affairs Bureau by hand or by post at or before
5:00 pm on 31 December 2014 at the following address:
Home Affairs Bureau
13/F, West Wing, Central Government Offices
2 Tim Mei Avenue
Tamar
Hong Kong
Tel.:
3509 7001(Mr LAM)]
September 2014
18
Annex
Home Affairs Bureau
Scholarship Scheme to Promote Multi-faceted Excellence 2015-2016
Recommendation Letter Form
Reference for
(Name of Applicant)
1.
How long and in what context have you known the applicant?
2.
Please explain your reason(s) of recommendation (you may add a separate sheet
where necessary):
Date:
Name:
Organization:
Address:
Telephone no.:
Email Address:
Signature:
Position: