HSBC WATER PROGRAMME FOR INDUSTRIAL WATER MANAGEMENT
Application Form
OFFICIAL USE ONLY
Application No.:
Received Date:
APPLICATION FOR TECHNICAL ASSISTANCE TO CONDUCT GENERAL
WATER MANAGEMENT ASSESSMENT PROJECTS FOR FACTORIES
(FULLY SPONSORED BY HSBC)
Please complete this Application Form and send it together with the supporting documents by fax or mail to:
The Programme Secretariat
HSBC Water Programme for Industrial Water Management
Hong Kong Productivity Council
HKPC Building, 78 Tat Chee Avenue, Kowloon Tong, Hong Kong
Tel: (852) 2788 5349
Fax: (852) 2788 5608
Email: industrialwaterprogramme@hkpc.org
Web Site : www.industrialwaterprogramme.hk
For
Official
Use Only
PART I :
1.
PARTICULARS OF THE APPLICANT
Particulars of the Factory at which the General Water Management Assessment Project
will be Carried Out
Part I
1.
a) Factory Name
b) Factory Address
(Building)
(Street)
(District)
(City)
(Postcode)
c) Contact Person
☐ Mr ________________ ☐ Ms ________________
d) Position
e) Telephone
(
)
f) Fax
(
)
g) Email
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HSBC WATER PROGRAMME FOR INDUSTRIAL WATER MANAGEMENT
Application Form
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Use Only
h) Website (if any)
i) Year of Establishment
j) Business Registration
Number (see note 3,4)
k) Total sales revenue per
annum (Annual
Turnover)
l) Number of Employees
m) Industry Category
(please check the box)
- Electronics:
☐printed circuit board manufacturing
☐ semi-conductor manufacturing
☐ electronic components
☐ Others: _____________
☐
☐
☐
Metal finishing:
electroplating
anodizing
Others:_______________
☐
☐
☐
☐
Textile and leather:
textile bleaching & dyeing
textile laundry
leather tanning
Others:_______________
-
☐ Other Industry:
2. Particulars of the Parent Company in Hong Kong (if any)
Part I
2.
a) Company Name
b) Company Address
(Building)
(Street)
(District)
(City)
c) Telephone
(
)
d) Fax
(
)
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HSBC WATER PROGRAMME FOR INDUSTRIAL WATER MANAGEMENT
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e) Email
f) Website (if any)
g) Relationship with the
Factory
h) Number of Employees
PART II :
SELECTION CONSIDERATIONS
1. Resources to be Committed for this Project
1.1 Particulars of the Key Personnel to Take Charge of This Project
Name
☐ Mr ________________ ☐ Ms ________________
Part II
1.1
Position
Company
Office Direct Line
(
)
Mobile Phone
( 852
)
( 86
)
(
)
Fax
Email
Part II
1.2 Particulars of the Working Team
Name of Project Member
Position
1.2
Main Duties/Responsibility
in this Project
(1)
(2)
(3)
(4)
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HSBC WATER PROGRAMME FOR INDUSTRIAL WATER MANAGEMENT
Application Form
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2. Details of the Existing Water Management in the Factory
Part II
2.1 Basic Information of the Existing Water Management
2.1
Please provide the following basic information of water management in your factory. Use
separate sheet(s) if required:
a) General description of the
production process
b) Block diagram of the
production process (showing
sources of major water usage
and wastewater discharge)
c) Water consumption per month
d) Historical data of water
consumption
e) Wastewater discharge per day
f) Historical data of wastewater
discharge
g) Monitoring result of final
effluent
h) Wastewater treatment facilities
installed
i) General description of the
wastewater treatment facilities
j) Treatment capacity of the
wastewater treatment facilities
k) Design and operation
information of the wastewater
treatment facilities
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☐ Yes, as attached.
☐ Yes, to be provided during assessment.
☐ No, not available.
☐ Yes, as attached.
☐ Yes, to be provided during assessment.
☐ No, not available.
☐
☐
☐
☐
☐
☐
☐
☐
Yes, as attached.
Yes, to be provided during assessment.
No, not available.
Yes, as attached.
Yes, to be provided during assessment.
No, not available.
Yes (Please answer i, j and k.)
No (Please answer l)
☐ Yes, as attached.
☐ Yes, to be provided during assessment.
☐ No, not available.
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HSBC WATER PROGRAMME FOR INDUSTRIAL WATER MANAGEMENT
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l) Water recycling facilities
installed
m) General description of the
water recycling facilities
n) Treatment capacity of the
water recycling facilities
o) Design and operation
information of the water
recycling facilities
☐ Yes (Please answer m, n and o.)
☐ No
☐ Yes, as attached.
☐ Yes, to be provided during assessment.
☐ No, not available.
2.2 Major Concerns of the Existing Water Management
a) Problems and issues
encountered
(Please prioritize the problems and issues encountered.)
☐
☐
☐
☐
☐
b) Major needs in water
management
Part II
2.2
Excessive water use in production
Lack of wastewater treatment and/or recycling
facilities
Shortcomings in wastewater treatment and/or recycling
facilities
High treatment and disposal costs of wastewater
Non-compliance with the environmental regulations
(Please prioritize the major needs.)
☐
☐
☐
☐
Water saving in the production
Evaluation of the existing wastewater treatment and/or
recycling facilities
Upgrade of the existing wastewater treatment and/or
recycling facilities
Establish new wastewater treatment and/or recycling
facilities
2.3 Improvement Plan
Part II
a)
b)
Long-term goal for the
better water management
General description of the
long-term goal for the
better water management
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☐ Yes (Please answer b)
☐ No (Please answer c)
2.3
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HSBC WATER PROGRAMME FOR INDUSTRIAL WATER MANAGEMENT
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c)
d)
Solid improvement plan
for the existing water
management
Scope of the improvement
plan
e)
Time frame of the
improvement plan
f)
Achievement targets of the
improvement plan
☐ Yes (Please answer d, e and f.)
☐ No
3. Publicity & the Use of Project Results
Part II
3
Please confirm by checking the box below.
☐
Yes, I/we fully understand and agree with the terms of the Publicity and Use of Project
Results (see note 5,6) ; and we are willing to share our experiences and/or Project results
on the following platforms:
☐ experience sharing in seminars, workshops, conferences or exhibitions;
☐ attending media interviews
☐ sharing of Project results in any publicity materials and/or publications, including
guidebooks, to be produced under this Programme
☐ open for visits to study their water management practices
☐ No, I/we do not agree with the terms of the Publicity and Use of Assessment Results (see
note 5,6).
PART III : SUPPORTING DOCUMENTS
Part III
1.
Please check the boxes below relating the supporting documents for the application 1.
(please attach the supporting documents to this application form)
☐
Copy of Business Registration Certificate of the Applicant’s factory at which the
general water management assessment project will be conducted (see notes 3 and 4);
and
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HSBC WATER PROGRAMME FOR INDUSTRIAL WATER MANAGEMENT
Application Form
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☐
Other information in support of the application
(Please provide any information which would help support this application, e.g.
resources to be put by the Applicant, needs to achieve environmental compliance,
future plan after this Project is completed.)
PART IV : DECLARATION
I/We, the undersigned,
Part IV
(a) confirm that the information given in this application as well as the accompanying
information is true and correct that reflects the status of affairs as at the date of submission.
I/We understand that any inaccurate/incomplete information supplied in this application will
delay my/our application for the Technical Assistance to conduct General Water Management
Assessment Project (the Project) under the HSBC Water Programme for Industrial Water
Management (the Programme). I/We shall inform the Programme Secretariat immediately if
there are any subsequent changes to the submitted information.
(b) am/are willing to pursue improvement in water management.
(c) understand that the Programme Secretariat may conduct a site visit to our factory for
information collection/ verification prior to formal application vetting if needed. I/We will
provide necessary support to facilitate the Programme Secretariat’s work in this area.
(d) understand that any findings resulted from this Project may be consolidated by the
Programme Secretariat for dissemination to the industries without mentioning company
details of the participating factories. I/We will provide necessary support to facilitate the
Programme Secretariat’s work in this area.
(e) HKPC has adopted a Personal Data (Privacy) Policy. Information about the policy is
available at HKPC enrolment counters for collection. You may also contact our Personal Data
Controlling Officer for further details. We use your information to inform you of our latest
products or services offered by HKPC and its partners via email, fax or phone call. In order to
help provide our services, we provide information confidentially to specific partner, other
companies that work on our behalf or our individual affiliates.
☐ If you do not want to receive promotional materials, please mark a “X“ in the box on the left.
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HSBC WATER PROGRAMME FOR INDUSTRIAL WATER MANAGEMENT
Application Form
For
Official
Use Only
Authorized Signature of Applicant
with Company Seal
:
Name (IN BLOCK LETTER)
:
Position
:
Date
:
Notes for the Applicant:
1) Please complete all parts of the form. Please return the completed form attaching the necessary supporting
documents to the Programme Secretariat of the HSBC Water Programme for Industrial Water Management (the
Programme) at the address listed on Page 1 of this form.
2) Please ensure that all relevant parts of this form are completed and the information is accurate. If there is
insufficient space, please give details on separate sheets and attach the sheets to this form.
3) Please provide a valid business registration document to prove the legal status of the factory.
4) The information provided in this form will be used for processing the application for Outreach Technical
Assistance under the HSBC Water Programme for Industrial Water Management.
5) Successful applicant is allowed to publicize its participation in this Programme and the results on their own
initiatives through publications, seminars, workshops, conferences, exhibitions, site visits, etc, with prior notice to
HKPC. Acknowledgement of the HSBC Water Programme for Industrial Water Management must appear on all
the publicity/ events related as well as publications arising from the project.
6) Successful applicant may be required to share the findings of the assessment and experience gained with other
factories. The successful applicant may need to participate in the publicity and promotion activities of the
Programme when being invited by HKPC to share their experiences gained in the Project. These activities may
include seminars, media interviews, exhibitions, etc, as well as site visits to the successful applicant's factory on
the production/ treatment facilities where the assessment has been covered, as arranged by HKPC under the
Programme. Participation in these activities will be honorary.
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