Application for Replacement of Lifelong Learner Card.doc

Application for Replacement of Lifelong Learner Card 補領終身學員證申請表格 Application for replacement of Lifelong Learner Card is subject to approval of the School on receipt of the completed application form in person with a valid HKID (or an authorized person with a copy of the HKID of the applicant), a HK$50 processing fee, and a self-addressed envelope with sufficient postage and the damage card (if appropriate). 申請補領終身學員證須經學院批准方為核實，每張費用為港幣五十元正。申請者須攜同香港身份證親自遞交表格(或由代申請人連同香港身份證副本遞交)，以及交回已損毀的學生證 / 終身學員證(如適用)，並須附上一個貼足郵票之回郵信封。 Please make payment at any of our Enrolment Centres. If payment is made by cheque, please have it crossed and made payable to “HKU SPACE”. 請前往任何一間報名中心繳付費用。如以劃線支票付款，抬頭請書明「香港大學專業進修學院」。 OFFICE USE ONLY 由本學院填寫 Payment Type 交費類別 837 Prepared by 處理 Remarks 備註 Checked by 查核 Date Sent 送交日期 PART I 甲部: Student Particulars學生資料 Name: (Mr.先生/Mrs.太太/Ms.女士) 姓名 (in BLOCK LETTERS正楷) (surname姓氏) (other names別名) H.K.I.D. No.: Student No.: 香港身份證 學生編號 Contact No.: E-mail: 聯絡電話 電子郵箱 ( Part-time兼讀課程 ( Alumni 校友會會員 Programme : (Year: ) 就讀課程 (Please specify 請列明) PART II 乙部: Reason for Replacement 補領原因 (Please tick as appropriate 請剔合適方格) ( Loss 遺失 ( Damage 損毀 ( Amendment of Student’s Name 更改姓名 (Please attach the documentary evidence 請提交有關證明文件) ( Others 其他: ( Student Cardholders (non-expiry) 學生證持有人(未過期) (Please specify 請列明) (Please submit a recent photo for processing 請提交近照一張) Remarks: All fees paid are neither refundable nor transferable. 註: 一切已繳費用，概不退還或轉讓。 Postal Address 回郵地址 Name姓名 Address地址 Please complete this part in BLOCK LETTERS請以正楷填寫本欄