THE CHINESE UNIVERSITY OF HONG KONG

CW CHU COLLEGE

Application Form for College Bursary

(Academic Year 2014–15)

I. Personal particulars

Name (in English) / Name (in Chinese)
Sex* Male / Female / Student ID No. / HKID No.
Date of Birth
(DD / MM / YY) / Age
Year of Study / Faculty
Department / Programme
E-mail Address
Home Address
Mobile Phone No.
*Please delete as appropriate
II. FINANCIAL SITUATION OF HOUSEHOLD MEMBERS**
1. No. of Household Members (Including Applicant):
2. Income of Household Members
Name of Household Member / Relationship with Applicant / Age / Occupation / Monthly Income (HK$)
3. Other Income of Household Members (e.g. pension, public assistance, compensation, rental income, alimony and financial assistance from the Government / NGOs / other institutions or funds, etc.)
Name of Household Member / Description of Other Income / Aid Year / Amount (HK$)
4. Family Members Attending School in the Academic Year 2014–15 (Excluding Applicant)
Name of Household Member / School & Class Attended / Annual Net Tuition Fee#
** Household members include family members who contribute / expend family income on a regularly basis.
# Amount of tuition fee paid after deducting any awards/ financial assistance received.
5. Housing (Please ü the appropriate boxes)
Type: / Public Housing / Private Housing / Others (Please Specify) ______
Status: / Rented / Mortgaged / Owned
Monthly Rent / Mortgage Payment (HK $) ______
III. REASONS FOR APPLICATION (This session is compulsory.)
IV. FINANCIAL ASSISTANCE APPLIED IN THE ACADEMIC YEAR 2014 – 15 ( Please ü the Appropriate Boxes)
Financial Assistance Applied / Status
Tertiary Student Finance Scheme – Publicly-funded Programmes
(Government Grant and Loan) / Applied successfully
Amount: ______
Application in progress
Not Applied
Government Non-means-tested Loan Scheme / Applied successfully
Amount: ______
Application in progress
Not Applied
University Bursaries and Loans
CUADI (To be completed by the College Office):______/ Applied successfully
Amount: ______
Application in progress
Not Applied
Others (Please Specify):______/ Applied successfully
Amount: ______
Application in progress
Not Applied
V. SCHOLARSHIPS/ FINANCIAL ASSISTANCE RECEIVED IN THE PAST 12 MONTHS
Scholarships / Financial Assistance Received / Amount / Issued Organization

VI. Entrance Examination Results (Only for reference for borderline cases)

Entrance Examination Taken / HKDSE / IB / GCE / Others (Please specify)* ______
Subject / Grade / Examination Year
*Please delete as appropriate /

VII. Academic awards / Distinctions received in the past two years

(Only for reference for borderline cases)

Academic Awards / Distinctions / Year / Issued Organization
VIII. DECLARATION
I hereby declare that the information provided in this form and relevant documents attached are to the best of my knowledge. I understand that if I knowingly supply false information, CW Chu College has the right to rescind my offer of the bursary.
______
Date Signature of Applicant
Remarks: The personal data provided on this form and other relevant supporting documents attached will be used solely for processing this application, and will be destroyed when they are longer required.

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