SCE-R-012(06/2009)學歷證明書申請表ApplicationforReferenceLetter填報資料只供本項申請用途。有關申請手續，請參閱背頁之注意事項。Informationprovidedwillbeproceededforthisapplicationonly.Pleaserefertotheoverleaffornotesofapplicationprocedure.個人資料PERSONALPARTICULARS姓名(英文)中文姓名Name(English):_____________________________ChineseName:___________________________________________________香港身份證號碼電郵地址（請參閱背頁之注意事項6）HKIDNo.:__________________________________EmailAddress(SeeNotes6overleaf)_________________________________聯絡電話TelephoneNo.:(Office)_________________________(Res.)_________________________(Mobile)_________________________通訊地址Correspondenceaddress(請用正楷填寫PleaseprintinBLOCKletters):室Flat層Floor座Block大廈、屋苑、街號及街道英文名稱NameofBuilding,Estate,No.andNameofStreetinEnglish地區District:1.香港HongKong/2.九龍Kowloon/3.新界N.T.修讀課程資料COURSE/PROGRAMMEINFORMATION請於適用處Pleasewhereappropriate:短期課程-課程編號及名稱ShortCourses–CourseCode&Title:_________________________________________________________________________註冊編號修讀年份及學期EnrolmentNo.___________________________________StudyYear&Term:_________________________________________課程名稱ProgrammeName:________________________________________________________________________________________學生編號修業/畢業年份StudentNo.:____________________________________YearofAttendance/YearofGraduation:_________________________申請目的PURPOSEOFAPPLICATION請於適用處，並用正楷填妥有關的部份Pleasewhereappropriateandcompletetheappropriatepart(s)usingBLOCKletters.課程更改名稱證明CertificationforProgrammeRenaming原定課程名稱OriginalProgrammeName:______________________________________________________________________新課程名稱NewProgrammeName:___________________________________________________________________________其他證明項目(請列明)OtherCerificationItems(pleasespecify):____________________________________________________________________________________________________________________________________________________________領取方法(請)WayofCollection:(Please):於九龍塘校園中心思齊樓辦事處領取TobecollectedattheKowloonTongCampusCentreDLBOffice郵寄至上述地址Tobemailedtothe