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Application Form for Admission toIn-service Early Childhood Teacher Education Programmes 2005 Entry

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● Please read through the “Prospectus” and “Application Guide” carefully before completing this form.�� !"#$%�� !"#��� !"#$%�

● Please use BLOCK LETTERS in English with a black/blue ballpen. =�� !"#!$%&'()*+,-.

CHOICE OF PROGRAMME =�� !

Day Contact Telephone No. Ext. (if applicable) Evening Contact Telephone No. Ext. (if applicable)�� !"#$% ���� !" �� !"#$% ���� !"

Mobile Phone No. Fax No.�� !"# �� !

E-mail Address �� !"

Please enter information in this section as printed on your HKID card/passport. �� !"#$%&' ()*+,

Full Name in English �� !

Surname��

Other Names��

Name in Chinese Sex �� M = Male �

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Chinese Name in Code Date of Birth�� !"# �� !

Day � Month � Year �

H.K. Identity Card No. Passport No.�� !"#$ �� !

Local/Non-Local Applicant * L = Local �� Nationality�� L�� !"# * N = Non-local�� ��

* Local applicants are those who have a right of abode in Hong Kong, or have continuously resided in Hong Kong for three years on or before 1 September 2005.Otherwise, you will be regarded as a non-local applicant.�� !"#$ !"%&'()*+,��� !"#$%&'(�� !"#$%&'()*+,-./01234'

PERSONAL PARTICULARS �� !"

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For those applying for PGDE(ECE), please also complete the supplementary form. �� !"#"$%&�� !"#�� !"#$"%&'()*+,-

Correspondence Address (Please use BLOCK LETTERS in English.) lîÉêëÉ~ë=^ÇÇêÉëë EmäÉ~ëÉ “✓ ” ~ë=~ééêçéêá~íÉF�� !�� !"#$%&�� �� ! E�� !"#$ “✓ ” �F

CORRESPONDENCE INFORMATION �� !

( )

For Office Use �� !

Application No. �� !

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Programme Code �� ! Programme Title �� !

CHOICE OF CLASS VENUE* =�� !"# G

* To be completed by those applying for Programmes ▲E3B009 and E2C008 only. �� !▲bP_MMV�bO`MMU�� !"#▲ Some elective modules will be offered in the other campus. �� !"#$%&'()*+,

Venue �� Order of Preference �� !

Tai Po Campus �� !

Venue �� Order of Preference �� !

Town Centre �� !

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INFORMATION ON DISABILITY �� !"#

EDUCATION BACKGROUND �� !

Applicants with a disability please fill in the box “Y” and state the nature and degree of disability. Otherwise, please fill in the box “N”.

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Applicants with disabilities will be considered on the same basis with other applicants. Information about the nature and degree of any disabilities will helpthe Institute to assess if its facilities are adequate for applicants to benefit from the studies.

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From �(Year��)

To �(Year ��)

Name of Institute�� !

Country��

Period of Attendance�� Qualification Obtained / To be Obtained

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(e.g. Certificate in Child Care �� !"#$%&)

(A) mìÄäáÅ=bñ~ãáå~íáçå=oÉëìäíë=�� !"#

Please provide details of type of public examination, year of attempt and subject results. For “Exam” and “Subject” Codes, please refer to Tables 1 and 2 onpages 14-15 in the “Application Guide”.

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Please attach copies of certificates. �� !"#$%&'

Exam��

Year��

Subject��

Grade��

Subject��

Grade��

Subject��

Grade��

Subject��

Grade��

Subject��

Grade��

Subject��

Grade��

Subject��

Grade��

Subject��

Grade��

Subject��

Grade��

Subject��

Grade��

(B) mçëíJëÉÅçåÇ~êóLqÉêíá~êó=nì~äáÑáÅ~íáçå=�� !=ElíÜÉê=íÜ~å=íÉ~ÅÜÉê=ÉÇìÅ~íáçå=éêçÖê~ããÉë=�� !"#$%F

(C) mêçÑÉëëáçå~ä=qÉ~ÅÜÉê=nì~äáÑáÅ~íáçå=�� !"#

1. Have you obtained or are you currently studying for ‘Qualified Kindergarten Teacher (QKT)’ qualification?Please enter “Y” for Yes or “N” for No.�� !"#$%&"#�� !"#$%&�� !"#$%�v��� !�k��

a. Name and Country of Institution granting the above “QKT”qualification �� !�� !"#$%&�� !"#$%&'

b. Title of programme �� !

c. Classification of award (e.g. Distinction, Credit, Pass)==�� !�� !"#$%&$'()

d. Duration of the programme �� !"

e. (Expected) Month and year of graduation �� !�� !"#!

f. Number of years and months of teaching experience after obtaining QKT status (count up to 31 August 2005)==���� !"#$%&�� !"#$��� !""#$%&'()*+

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Month � Year �

Year(s) �

Years(s) � Month(s) �

Country ��

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2. Have you attended or are you attending ‘Certificate in Kindergarten / Early Childhood EducationProgramme (CE(KG)/CE(ECE))’ or equivalent? Please enter “Y” for Yes or “N” for No.�� !"#$%&"#�� !"�#$%&'()*�� !"#$%&'()*�v��� !�k��

a. Name and Country of Institution attending the above ‘CE(KG)/CE(ECE)’ programme �� !�� !"�#$%&'()*�� !"#$%

b. Title of programme �� !

c. Classification of award (e.g. Distinction, Credit, Pass)==�� !�� !"#$%&$'()

d. Duration of the programme �� !"

e. (Expected) Month and year of graduation �� !�� !"#!

f. Number of years and months of teaching experience after attending CE(KG)/CE(ECE) programme (count up to 31 August 2005)==���� !"�#$%&'()*�� !"#�� !""#$%&'()*+

^ka=L=lo� L�=====dê~ÇÉ=mçáåí=^îÉê~ÖÉ=Edm̂ F=�� !"#

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Month � Year �

Year(s) �

Country ��

Years(s) � Month(s) �

ADDITIONAL INFORMATION �� !

Please provide any information which you think is relevant to the assessment of your application, e.g. additional qualification other than the above teachereducation qualification. Attach additional sheet(s) if necessary.�� !"#$%&'()*+�,-./0123456789:;<=>?@.1AB5,CD3�EFGHB

3. Have you attended any additional teacher education programme other than QKT and CE(KG)/CE(ECE) programmeor equivalent (if applicable)? Please enter “Y” for Yes or “N” for No.��� !"#$%&'()*��� !"�#$%&'()*�� !"#$%&'()*+,-./0!"1

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a. Name and Country of Institution attending the above teacher education programme �� !"#$%&'()*+,-./

b. Title of programme �� !

c. Classification of award (e.g. Distinction, Credit, Pass)==�� !�� !"#$%&$'()

d. Duration of the programme �� !"

e. (Expected) Month and year of graduation �� !�� !"#!

^ka=L=lo� L�=====dê~ÇÉ=mçáåí=^îÉê~ÖÉ=Edm̂ F=�� !"#

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Month � Year �

Year(s) �

Country ��

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INFORMATION ON CURRENT TEACHING APPOINTMENT �� !"#

1. Name and Address of Current School / Centre �� !=L=�� !"#$

School / Centre Name:��=L=�� !"

School / Centre Address:��=L=�� !"

2. Please indicate your current posting in the registered early childhood education institution in the following table.Please “✓ ” in the appropriate box.�� !"#$%&'()*+,-./012'34�%56789":�✓ ���

For Office Use �� !

Registered Kindergarten �� !" Registered Child Care Centre �� !"#

Principal ��

Head Teacher (with adm.duties) ��=E�� !"#$F

Teacher ��

Teacher Assistant �� !

Others (Please specify)��=E�� F

Centre Supervisor �� !

Special Child Care Worker �� !"#$

Child Care Worker �� !"

Child Care Worker Trainee �� !"#$

Others (Please specify)��=E�� F

3. Please indicate the main medium of instruction used by the registered early childhood institution in which youare currently working. Please enter “C” for Cantonese, “P” for Putonghua, “E” for English and “O” for others.�� !"#$%&'()*+,-./0(123456789���`��� !"#�m��� !"

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4. Please indicate the total number of years and months of your teaching experience (including current school /centre): (count up to 31 August 2005)�� !"#$%&'(�� !"#$=L=�� ��� !""#$%&'()*+

5. Please indicate the total number of years and months of your teaching experience with PERMIT (includingcurrent school): (count up to 31 August 2005)�� !"#$%&'()*$+,-./�� !"#$%��� !""#$%&'()*+

OTHER FULL-TIME TEACHING EXPERIENCE �� !"#$%

Years(s) � Month(s) �

Years(s) � Month(s) �

Please list in chronological order. �� !"#$%&

From � To �

Name of School / Centre� � L �� !

Date (Month/Year)���� !"

Rank ��

(e.g. Kindergarten Teacher /Child Care Worker)

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Full-time /Part-time�� L��

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1. I declare that all the information given above in support of my application is to the best of my knowledge accurate and complete. I understand that anyomission or misrepresentation of information will lead to disqualification of my application for admission or subsequent enrollment in the Institute.

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2. I authorize The Hong Kong Institute of Education to

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(a) use my data as a basis for various types of processing in relation to my application;

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(b) have my personal data transferred to the student record system which may be used for statistical and research purposes by the Institute upon myadmission to the programme;

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(c) obtain from the relevant examination authority, assessment body or academic institution in Hong Kong and elsewhere information about my publicexamination results, records of studies or professional qualifications if deemed appropriate; and

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(d) use my data to carry out checks of my applications, and any records of my studies in the Institute and other institutions in Hong Kong and elsewhereif deemed appropriate.

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Signature of Applicant Date

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DECLARATION =��

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(It is at the applicant’s discretion to invite the employer to complete this section. �� !"#$%&'(�)*+,-./)

● This recommendation form should be completed by your current employer. Priority for admission will be given to applicants who are recommended by

their employers.�� !"#$%&'()*+,-� %./01-2345,

● The completed recommendation form should be submitted in a sealed envelop, together with the application form to the Institute.

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● In accordance with the Personal Data (Privacy) Ordinance, the information provided here will be released to the applicant on his / her request.

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1. I certify that Mr / Ms* is a serving full-time Principal /

Panel Chairperson / Teacher / Others* (please specify ) in my school / centre.

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2. Do you recommend the applicant to study the programme for which he / she applies?Please enter “Y” for Yes or “N” for No. Please state the reasons below:�� !"#$%&'()*+,-./012�3$4�v��� !�k��� !"#$%&'

3. If you recommend the above named applicant and there are more than 1 staff member applying for the programme, please put a “✓ ” in the appropriatebox to indicate the priority of your recommendation (this item is optional for completion):�� !"#$%&'()*+,-./012+345%6789:;<"�✓ ��� !"#$%&'()*+,�� !"#$%&'(�

1 st ��

2 nd ��

3 rd ��

4 th ��

RECOMMENDATIONS �� =Eqç=ÄÉ=ÅçãéäÉíÉÇ=Äó=íÜÉ=ÅìêêÉåí=ÉãéäçóÉê=�� !"#$F

Signature of Principal / Teacher / Employer / Academic Referee*:��=L=��=L=��=L=�� =G��

Name of Principal / Teacher / Employer / Academic Referee*:��=L=��=L=��=L=�� =G��

EmäÉ~ëÉ=ìëÉ=_il`h=ibqqbo=�� !"#F

Name of School / Organisation*:��=L=��=G��

EmäÉ~ëÉ=ìëÉ=_il`h=ibqqbo=�� !"#F

Date:��

* Please delete whichever is inappropriate.�� !"#$%&

School / Centre Seal��=L=�� !

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APPLICATION FEE ��

Please stick the receipt of application fee below:�� �!"#$%&'(

Please stick here the original customer copy of the Deposit Slip or ATM Advice��� !�� !"#�� !"#������ !

CHECKLIST ��

For Office Use �� !

Application No. �� !

0 5

Before submitting your application, please check if you have:�� !"#$!%&'()*+

✓ filled in the correct programme code and title;

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✓ filled in the required supplementary from (if applicable);

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✓ stuck the receipt of application fee;

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✓ attached a copy of each of academic documents# stated in the application;

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✓invited your employer to complete the recommendation form (if applicable); and

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✓signed and dated the application form.

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# Applicants who have completed programmes offered by the Institute from 1995 NEED NOT send any copies of certificates and transcripts of studies obtained at this Institute.You are, however, required to authorize the Institute to extract and use your records of studies at the Institute for the purpose to process the applications.

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