提名表格Nomination Form

1、提名表格提名表格 Nomination Form(本頁必須由推薦機(jī)構(gòu)/院校填寫 This page must be filled in by the nominating organization / institution)本人現(xiàn)提名 （被提名人姓名）參加龍匯 100華人青年領(lǐng)袖論壇 2008。如提名多於一位，請按優(yōu)先排序：第 名I would like to nominate (Name of Nominee) to attend the Dragon 100 Young Chinese Leaders Forum 2008.Please prioritize your nominatio

2、ns if there is more than one nominee: Priority No: 提名人姓名 Name of Nominator: (教授/博士/先生/太太/小姐) (Prof / Dr / Mr / Mrs / Ms)姓氏 Surname: 名字 First Name: 機(jī)構(gòu) Organization: 職位 Position: 通訊地址 Correspondence Address: 電話 Tel. No.: 傳真 Fax No.: 電郵 E-mail Address: 與被提名人之關(guān)係 Relationship to Nominee: _推薦評語(如有需要，請另頁書寫

3、) Comments regarding Nominee: (use separate sheet(s) if necessary)提名人簽署Signature of Nominator:機(jī)構(gòu)印鑑Chop of Nominating Organization / Institution: 請將填妥之提名表格和有關(guān)之證明文件於二零零八年五月三十日二零零八年五月三十日或以前寄往龍傳基金秘書處 香港皇后大道中九十九號中環(huán)中心地下六至七室Completed Nomination Form together with copies of documentary evidence, should be s

4、ent to the following address on or before 30 May, 2008.The Secretariat, The Dragon Foundation, Unit 6-7, G/F., The Center, 99 Queens Road Central, Hong Kong. 龍匯龍匯 100 華人青年領(lǐng)袖論壇華人青年領(lǐng)袖論壇 2008Dragon 100 Young Chinese Leaders Forum 2008二零零八年八月二十二日至三十日22 30 August 2008An advocate for youth leadershipA bel

5、ief in exchange networksA commitment to Chinese heritage提名編號 (本會填寫)Nomination No. (Official Use Only)_由被提名人填寫由被提名人填寫 To be Completed by Nominee(請於填寫前詳閱填寫表格細(xì)則表格可於 下載)(Please read the Application Guidelines available at before you fill in the form)I. 個(gè)人資料個(gè)人資料 Personal Particulars 姓名 Name: (Surname) (F

6、irst Name) (英文 English) (姓氏) (名字) (中文 Chinese)出生日期(日/月/年) Date of Birth:(dd/mm/yy) 年齡 Age: 出生地點(diǎn) Place of Birth: 性別 Sex: 國籍 Nationality: 於提名機(jī)構(gòu)所屬國家居住年期 Years of Residence in Country of nominating organization: _(年期 no. of years) _(國家 country)華裔 Chinese Ethnicity: 父系 Paternal母系 Maternal 兩者 Both語言 Langu

7、age(s): 英文 English卓越 Excellent流利 Fluent基本 Basic不懂 Incomprehension普通話 Putonghua卓越 Excellent流利 Fluent基本 Basic不懂 Incomprehension其他 Others:_卓越 Excellent流利 Fluent基本 Basic不懂 Incomprehension其他 Others:_卓越 Excellent流利 Fluent基本 Basic不懂 Incomprehension旅遊證件 Travelling Document:類別 Type: 有效日期至 Expiry Date:證件號碼 Do

8、cument No.: 簽發(fā)機(jī)關(guān) Issuing Authority: 須申請簽證往 Need to apply Visa to: 香港 Hong Kong 內(nèi)地 Mainland China(被提名人需自行辦理簽證) (Nominees should apply for their own Visa)II.通訊資料通訊資料 Correspondence 通訊地址 Correspondence Address: 電話 Tel. No.: ( ) (住宅 Residence) (手提 Mobile)(國家編號) 區(qū)號 電話號碼(country code) area code no.Fax No.

9、傳真: ( ) 電郵 E-mail Addresses: 1. (國家編號) 區(qū)號 電話號碼 2. (country code) area code no. 住宅地址 (如與通訊地址不同)Residential Address (if different from correspondence address): 緊急聯(lián)絡(luò)(於申請人居住國家/地區(qū)) Emergency Contact (in country of residence):緊急聯(lián)絡(luò)人姓名 Name of Contact Person:_關(guān)係 Relationship: 地址 Address: 電話 Tel. No.: ( ) (日

10、間 day)( ) (夜間 evening)電郵 E-mail Address: 近照Recent photoIII.教育背境及工作履歷教育背境及工作履歷 Education Background and Work Experience (1) 現(xiàn)正就讀院?，F(xiàn)正就讀院校/在職資料在職資料 Particulars of Current Academic Programme/Employment院校/機(jī)構(gòu)名稱 Name of Institution/Organization: 學(xué)院/部門 Faculty/Department: 主修科目及年級(2007/08 年間) Major & Year of

11、 Study(in 2007/08): 職位及職系 Position Held & Rank: (2) 學(xué)歷學(xué)歷* Academic Background* (由最近就讀之院?；蜃罡邔W(xué)歷開始順序列出,包括中學(xué) Begin with institution last attended or highest educational level attained up to and including secondary/high schools attended)請附上本學(xué)期或上一學(xué)期之成績表副本Please attach a copy of the transcripts or school r

12、esults of previous or last years studies.年份 Year院校名稱 Name of Institution將/已獲取之專業(yè)資格/證書 Level to be Attained/Attained(3) 工作經(jīng)驗(yàn)工作經(jīng)驗(yàn)* Work Experience* (由最近之工作經(jīng)驗(yàn)順序列出 Begin with the recent work experience)年份 Year機(jī)構(gòu)名稱 Name of Organization職位 Position Held IV. 學(xué)術(shù)成就學(xué)術(shù)成就* Academic Attainments* (由最近獲取之成就開始順序列出,

13、最早可追溯至中學(xué)階段 List the recent attainments up to secondary/high schools)年份Year獎(jiǎng)學(xué)金/獎(jiǎng)項(xiàng)名稱Name of Scholarship/Award獲獎(jiǎng)級別(國際級, 國家級, 地區(qū)級別等)Level of Achievement(International, national, regional, etc.)頒發(fā)機(jī)構(gòu)Awarding AuthorityV. 非學(xué)術(shù)成就非學(xué)術(shù)成就* Non-Academic Attainments* (由最近獲取之成就開始順序列出, 最早可追溯至中學(xué)階段 List the recent atta

14、inments up to secondary/high schools)1. 比賽比賽 Competition年份Year範(fàn)疇(例如：運(yùn)動、音樂、藝術(shù)等)Area of Competence(e.g. sports, music, arts, etc.)所獲之獎(jiǎng)項(xiàng)Prize/Award Received獲獎(jiǎng)級別(國際級,國家級,地區(qū)級別等)Level of Achievement(International, national, regional, etc)頒發(fā)機(jī)構(gòu)Awarding Authority2. 技能技能 (例如：運(yùn)動、音樂、藝術(shù)等例如：運(yùn)動、音樂、藝術(shù)等) Skill (e.g.

15、 sports, music, arts, etc.)技能Area of Skill所獲之獎(jiǎng)項(xiàng)Prize/Award Received獲獎(jiǎng)級別Level of Achievement卓越 Excellent優(yōu)異 Good優(yōu)良/良好 Skillful一般 Average卓越 Excellent優(yōu)異 Good優(yōu)良/良好 Skillful一般 Average卓越 Excellent優(yōu)異 Good優(yōu)良/良好 Skillful一般 Average卓越 Excellent優(yōu)異 Good優(yōu)良/良好 Skillful一般 AverageVI. 課外活動課外活動/社區(qū)服務(wù)社區(qū)服務(wù)* Extra-Curricul

16、ar Activities/Community Services* (由最近獲取之成就開始順序列出 begin with recent attainments attained)1. 課外活動課外活動 Extra-Curricular Activities年份/時(shí)段 (月份/年份)Year/Duration (mm/yy)由 From 至 To機(jī)構(gòu)Organization負(fù)責(zé)職位/成就Position Held/Achievements機(jī)構(gòu)級別(國際級, 國家級, 地區(qū)級別等)Level of Scale (International, national, regional, etc)2. 社

17、區(qū)服務(wù)社區(qū)服務(wù) Community Services年份Year活動內(nèi)容及舉辦機(jī)構(gòu)Event & Organization負(fù)責(zé)職位/成就Position Held/Achievements活動類型級別(國際級, 國家級, 地區(qū)級別等)Level of Scale (International, national, regional, etc)服務(wù)時(shí)段(年期/時(shí)數(shù)/一次性)Duration(No. of Years/days/Single Event)*請?zhí)峁┯嘘P(guān)之證明副本*Please provide documentary evidence wherever possible從甚麼途徑得知有

18、關(guān)活動? Where did you learn about the Programme?大學(xué) (請?jiān)]明有關(guān)部門: ) University (Please specify the department: ) 機(jī)構(gòu) (機(jī)構(gòu)名稱: ) Organization (Name of Organization: )網(wǎng)上廣告 Online Advertisement 龍傳基金網(wǎng)頁 The Dragon Foundation Website 朋友 Friends 其他 (請?jiān)]明: ) Others (Please specify : )VII. 聲明聲明 Delcaration本人聲明上述所提供資料均正確無誤，倘有失實(shí)，本人明白主辦機(jī)構(gòu)有權(quán)取消本人之申請資格。本人身體及精神均屬健康，並能完全應(yīng)付是項(xiàng)活動。本人承諾於活動期間必盡所能、積極參與。I declare that the details given above are correct and I understand that any misrepresentation of facts would lead to disqualification of the application. I am phys