Personal Particulars Name in English (Mr/Mrs/Miss/Ms) Name in ...

APPLICATION FOR PROVISION OF WAITING ROOM SUPERVISOR SERVICEAS AN INDEPENDENT CONTRACTORNotes to Applicants in Relation to Personal Data (Privacy) Ordinance :• Applicants are not obliged to provide the requested personal data on this application form. However, such information isimportant so as to enable the Hong Kong Examinations and Assessment Authority (the Authority) to process and consider yourapplications.• The information provided on this form will be kept confidential and used exclusively for consideration of appointing applicantsfor Waiting Room Supervisor service conducted by the Authority for 12 months, after which, the information will be destroyedunless otherwise agreed by the applicant.Personal ParticularsName in English (Mr/Mrs/Miss/Ms) Name in Chinese Chinese name in codeH.K. Identity Card/Passport no. Date of birth Day-time contact telephone no.Residential/Correspondence addressHome telephone no.Email addressFax no.Education (in chronological order)Schools, Colleges, Universities, etc. attendedClasses attendedDate (month/year)FromToAcademic attainment (in chronological order)Exact description of academic/professionalqualifications held and issuing authority with dateExact description of subjects passed and exact level attainedi.e. Grade, Pass, Credit, Class, Division etc.Full employment record to date (in chronological order)Position held with briefDate (month/year)Name of organizationdescription of duties From ToP.T.O.

- 2 -Please answer the following questions:1. Language proficiency (Please delete where inappropriate)a. Fluency in Cantonese Very fluent / Quite fluent / Not fluentb. Fluency in English Very fluent / Quite fluent / Not fluentc. Fluency in Mandarin Very fluent / Quite fluent / Not fluent2. Experience as provider of Waiting Room Supervisor ServiceName of Examination Year Studio3. Connection with ABRSM exams candidates and full-time employee of the Authority: (Please delete whereinappropriate)a. Are you a music teacher? Yes / Nob. Have you entered students/relatives for the ABRSM Practical Exams – Aug to Nov 2013? Yes / NoIf yes, please write down the Demand Note Nos. for your entries ___________________________________c. Do you have any close relative (including spouse, children, parents, brothers and sisters) serving as a full-timeemployee of the Authority? Yes / NoIf yes, please give the full name of the relative4. Indicate the area you would like to be assigned. (Please indicate your order of preference by putting 1,2,3 etc.in the appropriate boxes.)Kowloon (East of Junction Road, Tseung Kwan O)Kowloon (West of Junction Road, Tsim Sha Tsui)Hong Kong (Causeway Bay, Wan Chai, Central, Sai Wan)Hong Kong (Shaukeiwan, North Point)Hong Kong (Aberdeen)NT (Tai Po, Fanling, Sheung Shui)NT (Shatin, Fo Tan, Ma On Shan)NT( Tsuen Wan, Tsing Yi)NT (Tuen Mun, Yuen Long, Tin Shui Wai)NT (Tung Chung)5. RefereeI hereby give consent to the Authority to obtain reference from the following person, who is not my next of kin, if I havebeen shortlisted for interview.Previous Employer (or a person who can provide information about your employment record and experience):NameOrganisationAddressTelephone6. Are you a candidate with disability? No Yes (Please the appropriate box)PositionRelationshipIf yes, please indicate nature and degree of disabilityIf yes, please specify special arrangement required for you to attend the interview(Note : Candidates with disabilities are considered on equal terms with other applicants and will be given an appropriatedegree of preference for appointment if they are found suitable. Candidates may be required to produce medical proof oftheir disability.)

- 3 -Remarks:a. The ABRSM practical exams will take place from Tuesday through Saturday every week, excluding General Holidays.Providers of Waiting Room Supervisor service will be expected to arrive at the examination studios daily at 8:30am and leave at approximately 5:30 pm, after the departure of the examiners in the studios.b. The service providers are expected to be on duty for the whole period once appointed. Absence on examination daysor seek replacement without the prior approval of the HKEAA is strictly forbidden.c. If appointed, the service providers will need to attend a briefing session. Details of the briefing session will benotified later.d. If appointed, the service provider will provide the Waiting Room Supervisor Service as an independent contractor.Nothing in the appointment of the service provider shall constitute or deem to constitute a contract of employmentbetween the Authority and the appointee.Declaration1. I understand that if I willfully give any false information or withhold any material information, I shall render myselfliable to dismissal if I am appointed to the above provision of service. I also give my consent for the release of mypersonal data by relevant Government departments/agencies to the Hong Kong Examinations and Assessment Authorityfor purposes in connection with my application and appointment for provision of Waiting Room Supervisor service. Iunderstand that the appointment, if offered by the Hong Kong Examinations and Assessment Authority, is a contract forthe hire of service as stated in Remarks d. above.2. I *have/have not been convicted of a criminal offence in a court of law.* Please circle whichever applicable. A criminal conviction is not necessarily a barrier to appointment by the Authority.Signature ____________________________________________Date ______________________________________Notes:1. Short-listed applicants will be notified in due course. Applicants who receive no reply by 9 September 2013 shouldconsider their application unsuccessful.2. For correction of or access to personal data after submission of the application form, please contact the IPED(ABRSM) of the Authority.