1971-HKRS30-16-30_Part04 — Page 23

54

(1) Places of education:

(m) Other relevant information 其他有關资料

55

Se NOTE 3.

參閱附註三

Name of schools

按

Date of entry

Date of leaving

and

疏

離校ㄖ期

2.

The following persons who are/are not aware of the statements

S

NOTE +.

(month and year)

(month and year)

G

龜閱附註四

universities 大學名蒯

(響眄佣年何月)

made on this form may be referred to as regards my character:

(a) Name (Mr./Mrs./Miss)

【甲】姓名(先生/夫人/小姐)

(i)

(11)

Educational qualifications (degrees, diplomas, certificates) 學歷楷

文

(A) Details of occupations, other than teaching, since completion of

之類

odocation

Details of all teaching experience:

Date of

Date of

commence-

leaving

School

任職日期

離職日期

Classes Subjecu taught taught

學校名稱

Amonth and year)

所数

所敷

and year)

班敝

科目

(填雎何伴

荷月)

I

Address

地址

Occupation

(b) Name (Mr./Mrs./Miss)

(芯)姓名(先生/夫人/小姐)

Address

她址

Occupation

3. I afx above a signed full face photograph of myself and attach 本人已在上面貼上要接待方正面常身图片一、海随

three signed copies of such photograph to this forra.

4. I attach-

(a) a medical certificate as to my health; and

(b) my educational certificates,

5. I am aware that if a permit to teach is issued in respect of the

五

.

above application, it will apply only to the school specified in paragraph i

of Part 1 of this formz.

任我好

-

6. The contents of this Part of this form are true and complete to 六據本人所知

勖

the best of my knowledge and beljef.

⁂項均阋跸盡速確實無訛。

Date

日期

(Signed) *riers

I

**(Proposed permitted teacher).

(擬受聘之准用歌凤〕

See NOTE 5.