Application Form for Outbound Student Exchange 2017-18

For current year 2 students in our UGC 4-year program

Please indicate the semester you would like apply for exchange:

Please tick one ONLY

Semester One

 Semester Two

Application deadline: 9Jan 2017 noon

1. PERSONAL DATA

Full Name in English: ______(Surname) ______(Given Names)

Full Name in Chinese:______(Surname) ______(Given Names)

Date of Birth: ______(Day/Month/Year) Gender: ______(M/F)

Place of Birth: ______Nationality: ______

Correspondence Address: ______

______

______

Contact Number: ______(Mobile) ______(Home)

E-mail Address: ______

Current Program at SHTM: ______

Stream: ______Year of Study: ______Student ID No.: ______

2. EXCHANGE DETAILS

First Choice:

Name of the University: ______

Name of the Department: ______

Program Title: ______

Subjects to be taken at the host department (Please refer to the latest information provided by the host department on its respective website):

Subject Title / Subject Code

Second Choice:

Name of the University: ______

Name of the Department: ______

Program Title: ______

Subjects to be taken at the host department (Please refer to the latest information provided by the host department on its respective website):

Subject Title / Subject Code

Third Choice:

Name of the University: ______

Name of the Department: ______

Program Title: ______

Subjects to be taken at the host department (Please refer to the latest information provided by the host department on its respective website):

Subject Title / Subject Code

Fourth Choice:

Name of the University: ______

Name of the Department: ______

Program Title: ______

Subjects to be taken at the host department (Please refer to the latest information provided by the host department on its respective website):

Subject Title / Subject Code

3. SUPPORTING STATEMENT

(On a separate sheet please provide a short account of why you are applying for this exchange programme and the reasons for you to select the three preferred institutions for your exchange.)

4. AUTHORIZATION AND DECLARATION

I authorize The Hong Kong Polytechnic University to use the data provided above for the following purposes:

i).As a basis for processing my application for admission as exchange student;

ii).For the University to extract from its records and for relevant institutions to provide the University with information about my studies;

iii).For transferring to the student record system upon acceptance of my application. The data together with my photo image collected at the time of registration will be used in activities in support of my study at the University including those conducted by the students’ organizations;

iv).For statistical and research purposes (all personal identifiers such as name, passport no., address and telephone no. will be deleted).

I declare that the information given in support of this application is accurate and complete.

I have attached the following documents in support of my application. (Please tick)

Copy of your most recent academic transcript in English

Curriculum Vitae in English

 Results of English proficiency tests taken (e.g. TOEFL, IELTS, etc.) if available

Copy of the supporting statement

Copy of subject descriptions of the chosen courses from the three preferred exchange institutions

Completed application form

Completed application and the required documentations must be submitted to Miss Keiko Tamof the General Office on or before the deadline.

Signature of Applicant: ______Date: ______

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