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["                                                             香港思源奖助学金申请表"]
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["学生姓名",{"$nulls":5}," (汉语拼音)",{"$nulls":7}," 性别"]
["身份证号",{"$nulls":6},"民族",null,null,"政治面貌"]
["出生日期",{"$nulls":3},"       年    月      日",null," 生源所在地",{"$nulls":4},"省               市               县"]
["学生类别",null,null,"    □烈士子女    □优抚家庭子女    □孤儿    □单亲家庭子女  ",{"$nulls":13},"         最近相片"]
[{"$nulls":3},"    □下岗职工子女      □残疾      □其它",{"$nulls":13},"            (必需)"]
["     院系",{"$nulls":4},"  学号",{"$nulls":5},"年级",null,null," (     年制)"]
["在校地址",{"$nulls":11},"宿舍电话"]
["家庭地址",{"$nulls":8},"邮编",null,null,"固定电话"]
["手机编号",{"$nulls":6},"e-mail/qq"]
[{"$nulls":9},"受资助情况"]
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["国家助学贷款",{"$nulls":8}," 减免学费",{"$nulls":9}," 如“其它”项"]
["香港思源",{"$nulls":8},"临时困难补贴",{"$nulls":9},"  目存在,，请在"]
["奖助学金",{"$nulls":8},"      借款",{"$nulls":9}," 备注栏补充完"]
["其它助学金",{"$nulls":8}," 勤工助学",{"$nulls":9}," 整相应名称"]
["其它奖学金",{"$nulls":8},"      其它"]
[{"$nulls":7},"在学校费用开支情况(上一学年)"]
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["  伙食费",{"$nulls":8},"  通讯费",{"$nulls":9},"如有“其它支出”"]
["  书本费",{"$nulls":8}," 其它支出",{"$nulls":9},"请在备注栏补充"]
["  日用品",{"$nulls":18},"完整相应名称"]
[{"$nulls":8},"家庭主要成员情况"]
["       姓名",{"$nulls":3},"  年龄","与申请人关系",null,"户口类别",null,"      工作(学习)单位",{"$nulls":4}," 职务",null,"月均收入(元) ",{"$nulls":3},"联系电话"]
[]
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[{"$nulls":9},"学习情况"]
["       年度成绩情况",{"$nulls":4},"      优秀科目(门)",null,null,"       良好科目(门)",{"$nulls":3},"        合格科目(门)",{"$nulls":5}," 不合格科目(门)"]
["  入学以来学习成绩"]
["  上学年度学习成绩"]
[{"$nulls":9},"申请理由"]
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["声明：本人保证以上所填报情况属实，并自愿加入我校思源社，积极参与公益活动，回报社会。"]
[]
["申请学生签名：",{"$nulls":10},"日期：            年      月       日"]
["                                                                                                                                                                                       "]
[{"$nulls":6},"   香港思源奖助学金申请表(续)"]
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["大学名称：",{"$nulls":11},"申请学生姓名："]
["                                     ",{"$nulls":8},"审核意见"]
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[" 班主任意见：",{"$nulls":10},"                         "]
[]
[]
[]
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[" 签字：",{"$nulls":10},"日期：               年      月       日"]
[]
[" 院系意见："]
[]
[]
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[" 负责人(签章)",{"$nulls":10},"日期：               年      月       日"]
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[" 学校主管部门意见："]
[]
[]
[]
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[" 负责人(签章)",{"$nulls":10},"日期：               年      月       日"]
[]
[" 送件人：                                       学工部收件人：                                    收到时间：        "]
[]
[" 香港思源奖助学金评审委员会意见："]
[]
[]
[]
[]
[" 负责人(签章)",{"$nulls":10},"日期：               年      月       日"]
[]
[" 思源基金会意见："]
[]
[]
[]
[]
[" 负责人(签章)",{"$nulls":10},"日期：               年      月       日"]
[]
[]
[{"$nulls":7},"      制窗体位：思源基金会"]
[{"$nulls":9},"        地址：香港  湾仔  告士打道 56号  东亚银行港湾中心 26楼"]
[{"$nulls":9},"    电话：852-2877-8988    传真：852-2877-0157    网址：www.siyuan.org.cn"]

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