LSF-0910


 

HKCC Learning Supports Fund 2009/10
2009/10


Application Form

(1)    ! "#%$ &(')(*+

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

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(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.
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(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):

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FGH e:‚ƒ„…(†(‡ Yes/ No/

(A) (1) FASP notification
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(2) NLSPS notification
(B) Other proofs of subsidy

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Proof of income for family member(s)
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Tax return
Employed/

š›œ Ž:648Income proof Bank statement

Unemployed/

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Last employment record


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(1) Father/ first guardian /

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(C)
(2) Mother/ second guardian /

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(3) Applicant

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(4) Unmarried family member 1
(5) Unmarried family member 2

Part 1 Personal Particulars ©«ª­¬¯®

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( Please tick the appropriate boxes ’√’)

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Name in English (as shown on HKID)
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Name in Chinese (as shown on HKID)

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Student No. WÁ AD HD Pre-AD

Correspondence Address …(ÅTÆ

Hong Kong
DE Kowloon [\ N.T. Ç:È
Contact Tel. No. ÉÊËÌ (Mobile ÍÎ ) Ï(Ð
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Personal Email

Part 2 Bank Account Information ÕÖ×ØÙ¬¯®

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

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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 š›%á1â ã 2(¦µ¶ ´ 9µ¶
Name used in Bank A/C (in English)
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Bank Code: š›%á1â që
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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(A) /  (B) /  (C) 

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

(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.
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 2009/10%'&

Type ,'-
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Name of organisation .'/ Ü Amount
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received

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(HK$)

(1) Grant

(2) Loan
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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
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copies of supporting
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documents.
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Amount of subsidy received in the following1months of 2009

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2009%
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Name of Organisation received ($)

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May June
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July Aug.
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(1)

(2)

(C) Family Income QSR6TUWVX

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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)
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and other unmarried
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working family member(s) living with you. )b'c
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(1) Ú(“:”(•–:l Ÿ >@ Îà —‰:648 Y ˜ .5<:= _

For those family members < who were employed in 2008-09,
2008-09%'&

please provide copies of their income proof(s) or tax return(s).

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(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
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employment record.
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2008-09%'&

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Name of family member -¦(3 Age (‰ Š«>@Ú2 ø E
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with
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applicant Annual
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income, if any
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Father/first guardian
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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. 2009/10%'& jwFxzy
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Yes/ƒ 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;

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b) where I have given my consent to such disclosure; and
c) 'ŒF
where such disclosure is authorised or required by law.

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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

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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.
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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
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and/or any misrepresentation will lead to disqualification
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of my application for the fund.
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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
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of my personal data by submitting a written
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request to the College.
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Name of Student
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Signature 

Date !#

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Bank Code š› ¶ö
Bank Name š› ¿ q
Bank Code š› ¶ö
Bank Name

DBS Bank (Hong Kong) Ltd. (formerly DBS Kwong On

011 American Express Bank Ltd. 032
Bank Ltd.)
DBS Bank (Hong Kong) Ltd. (formerly Overseas Trust
012 Bank of China (Hong Kong) Ltd. 052
Bank Ltd.)
Bank of China (Hong Kong) Ltd. (formerly Yien Yieh Fubon Bank (Hong Kong) Limited (formerly
014 128
Commercial Bank Ltd.) International Bank of Asia Ltd.)
Bank of China (Hong Kong) Ltd. (formerly Kwangtung
019 024 Hang Seng Bank Ltd.
Provincial Bank)
Bank of China (Hong Kong) Ltd. (formerly China & South
026 072 Ind. & Comm. Bank of China (Asia) Ltd
Sea Bank Ltd.)
Bank of China (Hong Kong) Ltd. (formerly Kincheng Banking Ind. & Comm. Bank of China (Asia) Ltd (formerly Fortis
030 029
corp.) Bank Asia HK.)
Bank of China (Hong Kong) Ltd. (formerly Sin Hua Trust
031 021 MEVAS Bank
Savings & Com. Bank)
Bank of China (Hong Kong) Ltd. (formerly China State Bank
033 043 Nanyang Commercial Bank Ltd.
Ltd.)
Bank of China (Hong Kong) Ltd. (formerly The National
036 022 Oversea-Chinese Banking Corp. Ltd.
Com. Bank Ltd.)
Bank of China (Hong Kong) Ltd. (formerly Hua Chiao
064 025 Shanghai Commercial Bank Ltd.
Commercial Bank Ltd.)
Bank of China (Hong Kong) Ltd. (formerly Po Sang Bank
070 003 Standard Chartered Bank
Ltd.)
027 Bank of Communications Co. Ltd. 061 Tai Sang Bank Ltd.
China Construction Bank (Asia) Corp. Ltd. (formerly Bank of
009 015 The Bank of East Asia Ltd.
America (Asia) Ltd.)
039 Chiyu Banking Corp. Ltd. 047 The Bank of Tokyo-Mitsubishi Ltd.
041 Chong Hing Bank Ltd. (formerly Liu Chong Hing Bank Ltd.) 004 The HK & Shanghai Banking Corp. Ltd.
250 Citibank (Hong Kong) Ltd. 071 United Overseas Bank Ltd.
018 CITIC Ka Wah Bank Ltd. 035 Wing Hang Bank Ltd.
Wing Hang Bank Ltd. (formerly Chekiang First Bank
040 Dah Sing Bank Ltd. 044
Ltd.)
016 DBS Bank (Hong Kong) Ltd. (formerly Dao Heng Bank Ltd.) 020 Wing Lung Bank Ltd.

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

HKCC Learning Support Fund 0910 – Application Form Page 3 of 3