0910 Learning Supports Fund_application Form[1]

LSF-0910


  

HKCC Learning Supports Fund 2009/10 2009/10



Application Form

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Closing date for application: 5:00 pm, Monday 23 November 2009 2009 11 23 ( )

(2)

Please submit your application together with copies of supporting documents in person to the Information Kiosk of HKCC on UG/F, Hung Hom Bay Campus, or 2/F, North Tower, West Kowloon Campus. Application without sufficient supporting documents will not be processed. ( )

(3)

Please tick the appropriate boxes below to indicate the supporting document(s) that you have attached to your application (you may tick more than one item): ‘ ’ ( ) Yes/

(A)

(B)

(1)

FASP notification

(2)

NLSPS notification

(C)

No/

Other proofs of subsidy

(1)

Father/ first guardian

(2)

Mother/ second guardian

(3)

Applicant

Tax return

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Unemployed/

Employed/

Proof of income for family member(s)

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Income proof

Bank statement

Last employment record

/

/

(4)

Unmarried family member 1

(5)

Unmarried family member 2

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( Please tick the appropriate boxes

Name in English (as shown on HKID) ( )

Name in Chinese (as shown on HKID) ( )

Gender

Student No.

AD

HD

M F

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Pre-AD

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Correspondence Address

Contact Tel. No. Personal Email

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(Mobile

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Hong Kong

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Kowloon

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N.T. (Home

Part 2 Bank Account Information

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If your application for this learning supports fund is successful, the College will credit the payment to the bank account you provide below. This bank account should be in your name. Please DO NOT fill in credit card account/ number. You may refer to the last page for the bank code. Kindly note that the below information will be used exclusively by Finance Office of PolyU for processing the payment regarding this fund.

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Bank Name

Bank Code:

Bank A/C No.:

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HKCC Learning Support Fund 0910 – Application Form




Page 1 of 3

LSF-0910 Part 3 Financial Status

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Please fill in Section (A) and/or Section (B)  and/or Section (C) and enclose all copies of supporting documents for assessment. For official use    (A) /  (B) /  (C) 

(A) Grant and Loan

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Please fill in the grant from FASP or loan from NLSPS, if any, that you received during 2009-2010. Please provide a copy of document on FASP or NLSPS notification. )('* '+    2009/10%'& Type ,'(1) Grant (2) Loan

Amount received ('0 1+ (HK$)

Name of organisation .'/

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(B) Other Subsidies 243"56

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Please fill in the subsidies, if any, that your family received from the HKSAR government or other organisations since May, 2009. Please provide copies of supporting documents. 87 =<'> )?'@BA 'C )H I  'D'EFD'G '.'/  2009% 5 9;:

Amount of subsidy received in the following1months of 2009 '('* )H + J9 2009%

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Name of Organisation .'/

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May 9

June L 9

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July 9

Aug. N 9

Sept.

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Oct.

Total amount received ($) P'H '+

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(1) (2)

(C) Family Income

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 p t =¦ ¡ §¢(Y :¤ ¥(¦> Þ t40 Ï 5 `¨ “7”(•(–7l 5‰Š _ Ú(“:”(•–:l Ÿ >@ Îà —‰:648 Y ˜ .5<:= _ Ú(“:”(•–:l 2Ÿ >@ Îà( 2(Ÿ:  g 6%8:9:;%<=> Ú š›œ e:f  îŸ %5 _ “:”(•(–:µ¶ -¦(3 (‰ Š«>@Ú2 ø E ¡¢ £ }¤¥¦ §¢ £] ¤¥¦ ¦

Please give details of your family income in 2008-09 (i.e. September 2008 – Aug 2009), which includes the income of you, your parent(s) / guardian(s) and other unmarried working family member(s) living with you. Y 1Z'[ )b'c  / 2008-09%'&]\ 2008% 9 9_^ 2009% 8 9a` (1)

For those family members < who were employed in 2008-09, please provide copies of their income proof(s) or tax return(s).  2008-09%'&

(2)

For those family members who were unemployed in 2008-09, please provide copies of their unemployment proof(s), such as bank statement(s) and<'last employment record. d d Z Ff)g 1e 2008-09%'& Name of family member

Age

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Relationship with applicant [ ji

Annual income, if any (HK$) k 1l %



Father/first guardian /

Mother/second guardian / Applicant

(D) HKCC Freshman Subsidy mnopWqsrut"vSq4

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Please indicate whether you have applied for the HKCC Freshman Subsidy of 2009/10. {'|z})~FF€F'‚

Yes/ƒ

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2009/10%'&

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No/„

HKCC Learning Support Fund 0910 – Application Form

Page 2 of 3

LSF-0910 Part 4 Authorisation and Declaration …†‡‰ˆ‹Š I authorise the PolyU Hong Kong Community College (the College) to use my data including the HKID number, public examination results and other qualifications, for activities relating to the handling and assessment of this application. I also authorise HKCC to disclose my personal data provided to those relevant parties including individual donors: a) for the above-mentioned purposes; b) where I have given my consent to such disclosure; and c) 'ŒF where such disclosure is authorised or required by law.  FŽ  ’‘ •”'– Y—˜j™'š F›1œ ' jž ( )“

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I also clearly understand that if I am granted the HKCC Learning Supports Fund (maximum amount ¯ $1,500), I shall undertake to repay the College the full amount of the fund if I do not complete my study for the academic year of 2009/10 at HKCC. I also understand there is no right of objection for me to the action(s) to be taken by the College to effect repayment for the captioned sum of money from me and my parents/guardians under the aforesaid circumstances. ±° F('² '+ F³ '´ K'µ lF¶ •·F¸F¹º)»z¼F½'¾1¿FÀFÁ ¾ ¾FÐÒÑ ' ( ) 2009/10 ÂFÃFĉÅIÆFÇ1È'É'Ê)Ë1ÌFÍ)ÎzÏ

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I declare that the information given in support of this application is accurate and complete. I understand that submission of more than one application to the'College and/or any misrepresentation will lead to disqualification of my application for the fund. Þ'ßFà 'áFâ 'ã'ä1å)æ'Ö)ç ±° Fè •í Fî'01ï 'é'ê

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I have noted, understood and agreed that under the provisions of the Personal Data (Privacy) Ordinance, I have rights to request access to, and to request thezcorrection of my personal data by submitting a written request to the College. ð Y B°òZ _ž)ó1ô ''ÜF01ZFù'ú 1ßFû 'ñ ­ Fü (õzö )÷Fø

Name of Student Date

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Signature




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Bank Code

Bank Name

011

American Express Bank Ltd.

012

Bank of China (Hong Kong) Ltd.

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052

039 041 250 018

Bank of China (Hong Kong) Ltd. (formerly Yien Yieh Commercial Bank Ltd.) Bank of China (Hong Kong) Ltd. (formerly Kwangtung Provincial Bank) Bank of China (Hong Kong) Ltd. (formerly China & South Sea Bank Ltd.) Bank of China (Hong Kong) Ltd. (formerly Kincheng Banking corp.) Bank of China (Hong Kong) Ltd. (formerly Sin Hua Trust Savings & Com. Bank) Bank of China (Hong Kong) Ltd. (formerly China State Bank Ltd.) Bank of China (Hong Kong) Ltd. (formerly The National Com. Bank Ltd.) Bank of China (Hong Kong) Ltd. (formerly Hua Chiao Commercial Bank Ltd.) Bank of China (Hong Kong) Ltd. (formerly Po Sang Bank Ltd.) Bank of Communications Co. Ltd. China Construction Bank (Asia) Corp. Ltd. (formerly Bank of America (Asia) Ltd.) Chiyu Banking Corp. Ltd. Chong Hing Bank Ltd. (formerly Liu Chong Hing Bank Ltd.) Citibank (Hong Kong) Ltd. CITIC Ka Wah Bank Ltd.

040

Dah Sing Bank Ltd.

044

016

DBS Bank (Hong Kong) Ltd. (formerly Dao Heng Bank Ltd.)

020

014 019 026 030 031 033 036 064 070 027 009

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Bank Code

128

Bank Name DBS Bank (Hong Kong) Ltd. (formerly DBS Kwong On Bank Ltd.) DBS Bank (Hong Kong) Ltd. (formerly Overseas Trust Bank Ltd.) Fubon Bank (Hong Kong) Limited (formerly International Bank of Asia Ltd.)

024

Hang Seng Bank Ltd.

072

Ind. & Comm. Bank of China (Asia) Ltd

029

Ind. & Comm. Bank of China (Asia) Ltd (formerly Fortis Bank Asia HK.)

021

MEVAS Bank

043

Nanyang Commercial Bank Ltd.

022

Oversea-Chinese Banking Corp. Ltd.

025

Shanghai Commercial Bank Ltd.

003

Standard Chartered Bank

061

Tai Sang Bank Ltd.

015

The Bank of East Asia Ltd.

047 004 071 035

The Bank of Tokyo-Mitsubishi Ltd. The HK & Shanghai Banking Corp. Ltd. United Overseas Bank Ltd. Wing Hang Bank Ltd. Wing Hang Bank Ltd. (formerly Chekiang First Bank Ltd.) Wing Lung Bank Ltd.

Note: The above List of Bank code'is?'for reference only. You should contact your bank for the bank code if you have any doubt. 1™ @ Ú 'ä

HKCC Learning Support Fund 0910 – Application Form

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