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The Hong Kong University of Science and Technology The Hong Kong Jockey Club Scholarship Scheme Application Form (2011/12)
Please return the completed application form, together with copies of supporting documents, to Scholarships & Financial Aid Office (Room 5016, 5/F (via lift no. 3), Academic Building, HKUST) by 5:30pm, 30 September 2011 (Friday).

A.

Personal Particulars 1. Name in full: *Mr/Miss

(in English) (in Chinese) (Others)

Photo

2.

Programme of Study:
(in English) (in Chinese)

3. Department: 4. Student No.: 5. 6. Date of Birth: Length of Residence in HK:

Year of Study: HKID No.: Place of Birth: Years: (from to )

7. Nationality: 8. 9. Address in HK: Home Tel. No.: Mobile:

10. Address in China (if applicable): 11. Tel. No. in China (if applicable): 12. University in China (if applicable): 13. Email Address:
(Assigned by Institution)

/
(Personal)

B.

Educational Background and Academic Achievements Page 1 of 5

(* please delete as appropriate)

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1. Names of Secondary Schools with dates and level attained (in chronological order): Name of Secondary School Dates Levels

2. Public Examination Results (please provide copies of supporting documents): * HKCEE / GCSE / GCEOL (in one sitting): Subject

Grade

Year

* HKALE / IB / GCEAL (in one sitting): Subject

Grade

Year

(* please delete as appropriate)

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3. Other public examinations or qualifications of significance, if any: (Please list only those received in the last 2 academic years and provide copies of supporting documents.)

4. External scholarships or prizes received in the past, if any: (Please list only those received in the last 2 academic years and provide copies of supporting documents.)

C.

Extra-curricular Activities/Community Service: (Please list only those in the last 2 academic years with supporting documents.) Year Name of Institution Name and Description of Programmes

D.

Personal Statements Applicant is required to provide a statement each in English and Chinese in your own handwriting, as follows: 1. Explain the reasons why you have chosen your particular programme of study and how this knowledge will enable you to serve yourself and the community. (500 words)

E.

2. () Checklist (Please check the below boxes to ensure the following required documents are enclosed to your completed application form before submission.) A recent photograph of the applicant to be attached to the Page 1 of the Application Form Public Examination Result Copy of supporting documents (Appendix No.: _____ ) Page 3 of 5

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Other Public Examination/Qualification of significance in the last 2 academic years (if any) Copy of supporting documents (Appendix No.: _____ ) External scholarships/prizes received in the past (if any) Copy of supporting documents (Appendix No.: _____ ) Extra-curricular activities/community service in the last 2 academic years Copy of supporting documents (Appendix No.: _____ ) Personal Statement 1 in English (Appendix No.: _____ ) Personal Statement 2 in Chinese (Appendix No.: _____ ) F. Declaration by Applicant I, (Name), declare that the information provided in this application is, to the best of my knowledge, complete and accurate. I have read and fully understand the Regulations of The Hong Kong Jockey Club Scholarship Scheme for which I am now applying. By signing below I promise to comply with the regulations and conditions of the Scholarship if awarded. I, (Name), also declare that I would sign an undertaking to observe all conditions of the Scheme upon receipt of the Hong Kong Jockey Club Scholarships if awarded.

Date:

Signature: (Applicant)

-------------------------------------------------------------------------------------------------------------------------------The personal information provided in this application form will be used for eligibility verification of the scholarship applicant, submission to scholarship donor and compilation of statistical data purposes.

G. University Recommendation (Remarks: Scholarships & Financial Aid Office will seek Schools recommendation document after the applicants are selected as the finalized nominees through the internal screening sessions so please leave it blank.)

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Name: __________________________________ Signature: ______________________________

Post: __________________________________ Date: __________________________________

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