新考试

APPLICATION FORM (REFUND OF EXAMINATION FEES)
FOR OFFICE USE ONLY Date Received: Candidate No.: 考試費用退款申請表

Please read the “Instructions to Applicants – Refund of Examination Fees” carefully before completing all parts of this form. Please write legibly in BLOCK LETTERS and in BLACK or BLUE INK. 在填寫此表格前請先閱讀“考試費用退款申請須知”。請用正楷及黑色或藍色原子筆清楚填寫表格。 PART 1: Examination Information第一部份：考試資料
(Please put a “9” in the appropriate ”??” 請於適當”??”內填上“9”號) Licensing Examination for Securities and Futures Intermediaries (LE) (Paper-based Examination (PBE) and Computer-based Examination (CBE)) 證券及期貨從業員資格考試(資格考試)(
筆試模式及電腦應考模式) ?? Paper 1 卷一 (Examination Code 考試編號 L
) ?? Paper 7 卷七 (Examination Code 考試編號 L
) ?? Paper 2 卷二 (Examination Code 考試編號 L
) ?? Paper 8 卷八 (Examination Code 考試編號 L
) ?? Paper 3 卷三 (Examination Code 考試編號 L
) ?? Paper 9 卷九 (Examination Code 考試編號 L
) ?? Paper 5 卷五 (Examination Code 考試編號 L
) ?? Paper 11 卷十一 (Examination Code 考試編號 L
) ?? Paper 6 卷六 (Examination Code 考試編號 L
) ?? Paper 12 卷十二 (Examination Code 考試編號 L
) HKSI Professional Diploma in Financial Markets 金融市場專業文憑 (PDFM) ?? Module 1 (Module Code單元編號 H
) ?? Module 5 (Module Code單元編號 H
) ?? Module 2 (Module Code單元編號 H
) ?? Module 6 (Module Code單元編號 H
) ?? Module 3 (Module Code單元編號 H

) ?? Module 7 (Module Code單元編號

H ) ?? Module 4 (Module Code單元編號 H ) Total Number of Examination Paper(s)/Module(s) 合共試卷/單元數目：__________ PART 2: Candidate Information第二部份：考生資料 Name in English：
英文姓名 Surname 姓氏
First Names 名字 Name in Chinese Day-time Contact Telephone No. 中文姓名：
日間聯絡電話號碼：


HKID Card No.
Or Passport No. 香港身份證號碼： 或 護照號碼︰ PART 3: Applicant’s Declaration第三部份：申請人聲明 I declare that I have read and fully understood the “Instructions to Applicants – Refund of Examination Fees”. I understand that only the examination fee(s) for the examination p

aper(s) / module(s) specified in Part 1 of this form will be refunded and an administration fee per examination per examination paper/module per examination mode per examination session will be deducted from the examination fee(s). I hereby apply for a refund of the examination fee(s) for the examination paper(s) / module(s) specified in Part 1 of this form and I understand that once the Hong Kong Securities Institute has received my application form, I cannot withdraw my application for a refund. I understand that the refund will be payable to me in Hong Kong dollars by cheque only. 本人謹此聲明已閱讀並清楚明白”考試費用退款申請須知”。本人明白香港證券專業學會只會退回本表格第一部份所填寫之試卷/單元的考試費用，並會於退回考試費用時，就每個考試每份試卷/單元每個考試模式每個考試試期扣除相關的行政費用。 本人現申請退回本表格第一部份所填寫之試卷/單元的考試費用，並明白香港證券專業學會於收到本人的申請表後，本人之退款申請將不能取消。本人明白退款只會以港幣支票形式支付予本人。
Signature of Candidate考生簽署：


Date 日期：
(should match with the HKSI’s records必須與學會記錄相符) For Office Use Only Handled by (Date):

( ) Cheque number: Completion Date: