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									                                          City University of Hong Kong
                                            Temporary Student Loan

                                                   Application Form
(Please read the Guidelines of Temporary Student Loan Scheme carefully before filling in the application form)

I.    Particulars of Applicant

      Name                                                                    Gender
                (English – in block letters)          (Chinese)
      Student No.                              CityU EID:                                     @student.cityu.edu.hk
      Home Tel. No.                         Mobile No.                                 Dept/Div
      Programme of Study                                                                              Year
      Home Address

II.   Information on Exchange study
      Host University for Exchange                                                         Country
      Exchange Period      From                       to                      Planned Departure Date
                                    (dd/mm/yyyy)              (dd/mm/yyyy)                               (dd/mm/yyyy)

III. Funding Support for the Exchange Study / Activity

                                                   Source                                               Amount
       1.    Student Exchange Fund offered by CityU (to be filled by Outbound Exchange Student)
       2.    Subsidy / Sponsorship offered by College / School / Department
       3.    Contributions of applicant and family members
       4.    Government Grant and Loan after deduction of annual tuition fee of the academic
             year of exchange (if you are waiting for the 2011/2012 G/L result, please make
             reference to your 2010/2011 G/L result)
       5.    Other sources of support (e.g. internal or external scholarships / bursaries) - please


                                                                                           Total :

IV. Estimated Expenditure for the Exchange Study / Activity
    (Please provide documentary proof for the Items stated in the below)

                          Item                         Amount in foreign       Amount (HK$)
                                                       currency (e.g. GBP,
                                                         US, RMB, etc)
                                                           (          )
      1.   Air fares and transport
      2.   Accommodation
           (total no. of weeks overseas: ______)
      3.   Meals
      4.   Insurance and Visa
                                             Total :

     Amount of temporary loan applied : HK$

V.   Family Condition
     (Please attach the latest three months relevant supporting documents e.g. income statement, copy of bank books,
     house mortgage, rental proof, etc.)

                   Name              Relationship   Occupation or Level of   Monthly    *Savings as at    Living
                                                           Study             Salary       Sep 2011       Together
      1. Applicant                   Self

      Monthly home mortgage/rental expenses : HK$

     *Savings of siblings who live away are not required

     Does your family face any financial hardship recently?

      No
      Yes, please specify

VI. Plan for loan repayment

    Please note loan recipients are required to repay the loan to the University within 6 months after the exchange
    study. Those who are on final year of study are also required to repay the loan by mid July before their
    graduation. The availability of loans relies very much on students’ punctual repayment of loans. Please state
    clearly your plan for repayment the loan if the loan is offered to you.

VII. Guarantors’ Information

     The following person has agreed to be my guarantor if the loan is offered to me:

     Name (in English)                                                        (in Chinese)
     Relationship                                          Contact Tel. No.

     A guarantor should fulfil the following conditions:
      a HK resident
      aged 21 or above
      gainfully employed with stable income

VIII. Agreement

      I understand that the information provided in this application form would solely be used for the assessment of
      my financial need. I declare that the information provided is true and complete and understand that any
      omission/misrepresentation of information with a view to obtaining pecuniary advantage by deception is an
      offence and is subject to disqualification of my application and university disciplinary action.

     Signature of Applicant                                                      Date

Checklist on copy of supporting documents to be submitted with the completed form:

□   Student I.D. card
□   Correspondence confirming the exchange status
□   Notification letter proving the amount of grant and loan received in 2010/2011
□   Income proof of all family members who live together (as at Sep 2011)
□   Bank books / statements of applicant and parents (Jul – Sep 2011)
□   Monthly home mortgage payment schedule or rental receipt (as at Sep 2011)
□   Other documents that prove your family’s financial need
□   Documentary proof of the estimated expenditure for the exchange study



1.        Financial Assistance Recommended :
          Name of award :                                                    HK$
          Name of award :                                                    HK$
2.        Purpose of assistance :

3.        Rationale :

4.       Special payment / repayment arrangement if application is approved

                          Signature of Interviewing Officer                      Date

                          Name of Interviewing Officer                       Post

         This application is :
         □      Approved / supported
         □      Not approved / not supported
                          Director of Student Development Services

          □         Approved
          □         Not approved
                                                              Vice-President (Student Affairs)
                                                              (for assistance amount > HK$10,000)
Update 27.9. 2011

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