An advocate for youth leadership A belief in exchange networks A commitment to Chinese heritage

PROGRAMME

Nomination no. ( Official Use Only )

2011

N OMINATION F ORM This page must be completed by the nominating university

I would like to nominate

(name of nominee) to attend the

Global Citizenship Programme 2011 in Bangkok, Thailand. Please prioritize your nominations if you have more than one nominee: Priority No: Name of nominator: ( Prof/Dr/Mr/Mrs/Ms* ) (Surname)

(First Name)

University:

Position:

Correspondence address: Tel. No.:

Fax No.:

E-mail address: Relationship with nominee: Comments on nominee: (use extra sheet(s) if necessary)

Signature of nominator:

Chop of nominating university:

: in English and copies of documentary evidence should be sent to The completed nomination form, essays the following address by

31 March 2011:

Global Citizenship Programme, c/o Institute of International Education, Room 601 General Commercial Building, 156 Des Voeux Road Central, Hong Kong.

* Please delete as appropriate.

To be completed by nominee (Please read the Application Guidelines available at www.dragonfoundation.net before you fill in the form.)

I. PERSONAL Name:

(English) (Chinese)

Date of birth: (dd/mm/yy)

Age:

Place of birth:

Gender:

Nationality:

Recent Photo

HKID No.:

Type of travel document: Expiry date: Document No.: Issuing authority: * Need for visa : Thailand:

Yes

No

Nominees must apply for their own visas if necessary

* Please tick as appropriate

II. CORRESPONDENCE Correspondence address:

E-mail addresses: 1. Tel. no.:

2. Fax no.:

Mobile phone no.: Residential address (if different from correspondence address):

Emergency contact: Name of contact person: Relationship: Address:

Tel. no.: Mobile phone no.: E-mail address:

(day)

(evening)

III. EDUCATION (1) Current academic programme Name of institution: Name of Faculty/Department: Major subject & year of study (in 2010/11): Please attach copies of current transcripts

(2) Academic background* (begin with your most recent institution)

Please attach copies of HKCEE & HKALE results and secondary school transcripts YEAR

NAME OF INSTITUTION

LEVEL (TO BE) ATTAINED

IV. ACADEMIC ACHIEVEMENTS* YEAR

NAME OF SCHOLARSHIP / AWARD

LEVEL OF ATTAINED

V. NON-ACADEMIC ACHIEVEMENTS* YEAR

AREA OF COMPETENCE (e.g. sports, music, arts, etc.)

(begin with most recent award)

(begin with most recent achievement)

PRIZE / AWARD

AWARDING AUTHOITY

VI. EXTRA-CURRICULAR ACTIVITIES/COMMUNITY SERVICE* (begin with most recent achievement)

YEAR / DURATION

EVENT / ACTIVITY

POSITION HELD / ACHIEVEMENT

ORGANIZATION

Please indicate if you have participated in programmes or events of the Dragon Foundation before: Yes

No Name of programme(s):

VII. LANGUAGE PROFICIENCY English:

Excellent

Very Good

Good

Basic

Putonghua:

Excellent

Very Good

Good

Basic

Others:

Excellent

Very Good

Good

Basic

Others:

Excellent

Very Good

Good

Basic

* Please provide documentary evidence wherever possible

VIII. ESSAY Please write an essay explaining briefly reasons for applying for the programme, views on the migration issues on international and regional level, its significance for world development and the average individual, and what you expect to give and gain from the programme experience. (1000 words)

IX. DECLARATION AND PERMISSION I have checked this nomination and its attachments and certify that all statements are correct to the best of my knowledge. I undertake to notify the organizer if there are any changes to the information provided. I give the organizer permission to verify information in the nomination and its attachments as well as permission to use the information as appropriate for publicity purposes.

Signature of Nominee:

Date:

Information provided by the nominee shall only be used for the purpose of nomination processing and programme promotion. Data of unsuccessful applicants shall be destroyed.

PROGRAMME

2011