SALES- F41 LOCAL APPLICATION FORM REV NO. 07 12 JUNE 2019 1

Local Application Form （本地学生报名表格）

Name as in NRIC/Passport 身份证姓名

Name in Chinese 华文姓名

Gender 性别

☐ Male ☐ Female 男 女

Date of Birth 出生日期

NRIC/ Passport No. 身份证/护照号码

Email Address 电邮

Home Tel No. 住家电话

Mobile No. 手机号码

Nationality 国籍

Country of Birth 出生国家

Race 种族

Residential Address 住址

Postal Code 邮区号码

Type of Pass Holder 通行证持有人类型

: Work Pass Holder 工作相关准证

Dependent Pass/ Long Term Visit Pass 陪伴型居留证/长期逗留准证

FIN No. 外国人准证号码

: Expiry date 有效期至

:

(B) CONTACT PERSON IN CASE OF EMERGENCY 紧急联系人资料 Name 姓名

: Contact No. 联络号码

:

Relationship: Spouse Parent Relative Friend Other _____________________ 双方关系: 配偶 家长 亲戚 朋友 其他

FOR OFFICIAL USE ONLY 仅供工作人员使用 *NOTE: Please complete all sections in ENGLISH. State 'NA' where it is not applicable. *注意：请使用英文填写报名表格里的每个项目，对于不适用的选项，请注明 'NA'。

Course Title 课程名称

:

Commencement Date 开课日期

: Full-time Part-time 全职 兼职

(A) PERSONAL PARTICULARS 个人资料

*NOTE: Please send the completed application form to our Serangoon Campus *注意：请将所有填妥的申请表格寄送至智源教育学院实龙岗校区。 587 Upper Serangoon Road Crestar Building Singapore 534564 Tel: (65) 6337 8338 Fax: (65) 6883 1098 Website: www.klc.edu.sg Email: enquiry@klc.edu.sg

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(C) EDUCATIONAL QUALIFICATIONS 学历

Name of School/College/University 学校名称

Country 国家

Medium of instructions授课语言

Period of Study 学习时段 Qualification Level 学历

From 始于

To 止于

(D) GOVERNMENT FUNDING ASSISTANCE - SSG/WSG (ONLY FOR SINGAPOREANS / SINGAPORE PRS)

学费资助（仅供新加坡公民/永久居民）

SSG/WSG funding is available for Singaporeans / PRs - 学费资助只适用于新加坡公民/永久居民

Self Funding (Please complete page 6 and provide guarantor’s signature) 费（请填写第 6 页并提供担保人的签名）

Company Sponsorship (Please complete section N) 公司资助（请填写 “N” 部分的项目）

Workfare Training Support (WTS) Scheme is ONLY available to Singapore citizens aged 35 yrs and above, earning a monthly income not more than $2,000 – WTS 津贴只适用于 35 岁或以上、正职并且月薪$2000 或以下的新加坡公民

(E) PRESENT EMPLOYMENT STATUS 目前就业详情

Employment Status 目前就业详情

: Currently Employed 目前在职

Currently Unemployed 待业

Retrenched 解除劳动合约

*If employed, please fill up the following details : *如有在职，请完成以下细节：

Part Time 兼职

Full Time 全职

Designation 现任职位

: Employment Start Date

就业日期 :

Salary Range 薪资范围

≤ $1000 $1001 - $1500 $1501 - $2000 $2001 - $2500 >$2500

Sector 行业

Childcare 托儿所

Kindergarten 幼稚园

Others, Please Specify: 其他, 请注明:

Company's Name 公司名称

:

(F) EMPLOYMENT HISTORY 工作经验

Name of Company 公司名称

Monthly Salary 工资

Occupation 职位

From 始于

To 止于

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(G) ADDITIONAL INFORMATION 附加资料

Please indicate how you come to know about this course. (Please tick the appropriate box) 请注明您如何知道有关的课程（请在格子里打勾）

Newspaper Advertisement, please circle: The Straits Times / TODAY / The New Paper / Lianhe Zao Bao/ MyPaper 报纸：海峡时报/ TODAY / The New Paper / 联合早报/我报

Flyers 宣传手册

Exhibition/Fairs 活动/讲座会

Email Direct Mailer 电子邮件

SMS (Mobile) 电话短信

Website 智源网站

Online Advertisement 网络搜索: 谷歌/雅虎/ MSN/其他 (请注明)

Referral：Friend/ Relative/ Employer 推荐：兄妹/同学/朋友/雇主

(H) HEALTH DECARATION (ALL APPLICANTS MUST COMPLETE) 健康状况

1) Do you have any medical history? Please tick the appropriate

请问你有没有任何病史？（请在格子里打勾）

Mental Illness 精神疾病

YES 是 No 否 Hepatitis B Carrier 乙型肝炎携带者

YES 是 No 否

Epilepsy 癫痫

YES 是 No 否 HIV/AIDS 艾滋病毒/艾滋病

YES 是 No 否

Tuberculosis 结核

YES 是 No 否 Others, Please specify 其他, 请注明

:

2) If you have answered “Yes” to Question 1, please provide details and supporting documents:

如果以上你有答是的话，请详细说明并递交附属文件：

HEALTH CLEARANCE REQUIREMENT: Early Childhood applicants are advised to visit www.ecda.gov.sg for health clearance medical check-up requirements.健康清关要求：请幼儿申请者访问 www.ecda.gov.sg 网站来了解关于健康清关的要求。

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(I) TERMS AND CONDITIONS 条款和条例

1) Students are required to sign the PEI – Student Contract on Course Orientation Day. 根据教育信托认证（EDUTRUST）的法定要求，学生必须和学校签署学生合约。

2) I agree and commit to work in a kindergarten/childcare centre subjected to the terms and conditions of KLCII for minimum 6 to 12 months period with effect from my course end date. (The course end date will be according to (PEI - student contract) – Only apply to WSQ Programme 我同意并承诺遵循 KLCII 的条款，在课程结束之日起将在托儿所/幼儿园里工作至少 6 到 12 个月。(课程结束时间依据本人的

学生合同) – 仅限于 WSQ 课程 3) I agree to be liable and undertake to pay KLC International Institute Pte Ltd the full portion of the supported course fee (SSG/WSG

Funding according to my student contract) in the event that I fail to complete and/or fulfil the above condition. 如果本人无法按照上述要求执行，将自行承担责任，并承诺支付给智源教育学院全额课程赞助费用（根据本人学生合同中的

SSG/WSG 的赞助信息）。 4) I will submit my employment letter to KLCII once I am employed by a kindergarten/childcare and will keep KLCII updated on my

employment status in writing through email or letter. 本人将及时向智源教育学院递交在幼儿园/托儿所的工作证明，并通过电子邮件或信件更新本人的工作信息。

5) I agree to furnish all required documents for funding application during enrollment of the course; thereafter any documents provided will not be considered. 我同意在入学之时提交所有赞助申请资料，任何在开课之后的赞助申请将不予考虑。

6) Information in the application will be treated with strict confidence and will be used solely for the purpose of course admission. 报名表格里的所有资料绝对保密，并仅限于入学申请的作用。

7) KLCII reserves the right to suspend the student's lessons until full payment of fee arrears is received. 智源教育学院有权力暂停学生上课，直至其还清学费为止。

8) All application fee, course fee, medical insurance and administration fees are to be paid directly to “KLC International Institute Pte Ltd”. 所有的报名费、学费、医疗保险费和行政费必须直接支付给“KLC International Institute Pte Ltd”。

9) Application fee is non-refundable and is only valid for 6 month period from the date of payment. 报名费恕不退还。自缴付日期起，有效期仅 6 个月，或直到所报读课程的开课日期（两者时限为最迟者）。超过此期限后，

该报名费将作废。 10) Fees paid are non-transferable.

所缴付的学费不能转让给他人。 11) Refund Policy (with reference to PEI-Student Contract)

退款规则（参照 PEI-学生标准合同)

% of [the amount of fees paid under Schedules B and C] [依附表 B 和 C 所支付的金额的百分比 (%)]

If Student’s written notice of withdrawal is received: 如果收到学生的书面撤回通知

[100%] More than [29] days before the Course Commencement Date

早于开课日期之前 [29] 日

[50%] Before, but not more than [29] days before the Course

Commencement Date 在开课日期之前，但不早于开课日期之前 [29] 日

[0%] After, but not more than [1] days after the Course Commencement

Date 在开课日期之后，但不晚于开课日期之后 [1] 日

[0%] More than [1] days after the Course Commencement Date

晚于开课日期之后 [1] 日

12) All requests for withdrawal or deferment of course must be submitted in writing to KLC International Institute Pte Ltd as stated in the

KLCII Student Handbook. 所有申请退学或推迟课程的学生必须以书面通知本学院的行政部。

13) KLCII reserves the right to change the class schedule or training venue due to unforeseen circumstances. 智源教育学院拥有权力，修改上课时间、地点、学费以及其他事项，无须事先通知。

14) Student must notify KLCII immediately of any changes in home address and/or handphone number. 若地址或联络号有任何更改，必须立即通知本学院的行政部。

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15) Permission is granted for the use of students' photos taken by KLCII during class or school events in all its advertisements and promotional materials. 本学院有权力把在课堂或学校活动中所拍摄到的照片，用于本学院的刊物和广告。

16) I agree to receive information and updates including promotional and marketing information from KLC International Institute. This consent overrides any registration with the DNC registry. 我同意接受所用的信息及更新消息，其中包括智源教育学院的宣传及营销信息。此声明将覆盖所有注册及 DNC 的注册规定。

17) KLCII reserves the right to amend the Terms & Conditions without prior notice. 本学院保留更改条款和条例的权力，无须事先通知。

18) For students who are holding any valid immigration passes, they are responsible for ensuring the validity of their passes (and any extension if necessary) for the full duration of the course. Students will NOT be allowed to attend class without a valid pass. 持有任何有效签证的学生，在接受课程时，必须自行确保签证的有效性（以及若有任何延期的需要）。如无有效签证，学生

将不准上课。 19) KLCII reserves the right to conduct course surveys with yourself and your employers after the course has ended.

本学院有权利在学生完成课程后对学生和学生的雇主进行咨询调查。 20) I understand that SSG/WSG, or its appointed auditor or nominated representatives may contact me directly to obtain information

deemed necessary for the purposes of conducting effectiveness survey or audits in relation to the Programme. 我了解，SSG / WSG 或其指定的稽核员或委任员可能会与我联系，以获得与本课程相关的反馈或审计项目所需的信息。

(J) DECLARATION BY APPLICANT 申请者声明 I, ____________________________________________________________________________________________________________

(NAME AND NRIC NO./PASSPORT NO.) declare that all information stated in this application is true and correct. I authorize any investigation of the above information for the purpose of verification. I understand that any misrepresentation or omission of information is sufficient ground for rejecting my application. 我承认以上的资料完全属实。我同意并授权学院审核以上资料。 The copies of the educational certificates and other educational testimonial documents submitted are true copies of the original documents which are authentic. 我承认所呈交的学历证书及学历证明书全属实。 I have read and accepted the above Terms & Conditions of KLC International Institute. 我同意和接受智源教育学院所有的条款和条例。 I consent to all personal data provided in this application to be used by KLCII for the purpose of course administration. 我同意在此申请表中提供的所有个人资料，将可以在本课程需要时使用。

Signature of Applicant 申请者签名

:

(K) DECLARATION FOR MEDICAL INSURANCE COVERAGE (ONLY FOR WORK PERMIT / STUDENT PASS/ DEPENDENT PASS /

LTV PASS HOLDERS) 免除声明 I declare that I am covered under my own medical insurance plan, (insurance company name) for hospitalisation and related medical treatment for the entire course duration. I will submit a valid copy of insurance policy. And I wish to decline the participation in the medical insurance plan available through KLC International Institute.

我特此声明我已经拥有自己的涵盖住院及治疗的医疗保险计划， (保险公司名称) 并且此医疗保险计划在整个课程阶段有效，我希望放弃参加智源学院提供的医疗保险项目。

I acknowledge that as a result of this declaration, I forfeit all rights to coverage otherwise available to me under the medical insurance plan provided by KLC International Institute. 我明白如果我放弃参加智源学院提供的医疗保险项目，我将无权享受该医疗保险项目产生的任何保障。

Signature of Applicant 申请者签名 :

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(L) THIS SECTION IS FOR SELF-FUNDED APPLICANTS - DEED OF GUARANTEE I, ____________________________________________________________________ agree to be a guarantor for (Name of Guarantor as per NRIC and NRIC No.)

_______________________________________________________________________ to undertake payment of the (Name of Student as per NRIC and NRIC No.) consumed course fees* in the event KLCII fails to receive the SSG supported portion of the course fee due to: a) the training grant for the student being rejected by SSG b) the student failing to pay the required course fee to KLCII on time c) the student breaching the terms and conditions of SSG d) the student withdrawing/deferring/transferring from the course or not completing the course by the stipulated course end date

* Consumed course fees are calculated based on this formula: Total Course Fees / No. of hours X No. of hours consumed If fees paid (based on payment schedule B as per student contract) is more than consumed course fees, there will be no refund of course fees. Dated this

Day of of in the presence of:-

(Day) (Month) (Year)

Signature of Guarantor :

Signature of Witness :

Name of Witness :

* A photocopy of guarantor’s NRIC must be submitted together with the application form.

A guarantor must be a Singapore Citizen / Singapore PR at least 18 years old

(M) TO BE COMPLETED BY RECOMMENDING AGENT/COMPANY/REPRESENTATIVE 代理公司/推荐单位/代表需填写此项目

Signature (Name)

签名（姓名）

Company Stamp

公司盖章

Date 日期

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(N) THIS SECTION IS FOR COMPANY-SPONSORED APPLICANTS HQ Details

Sector : Childcare Kindergarten Others, please specify :

Sponsored Candidate’s Name as per NRIC :

Name of Company : Company Registration No. :

Name of Centre : Centre’s Office No :

Centre’s Address :

Name of Contact Person: Contact No :

Contact Person’s Email Address :

Billing Company Name :

Billing Address :

ENHANCED TRAINING SUPPORT (ETS) GRANT FOR SMALL AND MEDIUM ENTERPRISE SMEs will enjoy government subsidies of 90% of the course fees when they sponsor their full-time employees for WSQ courses entitled for ETS funding (Refer to courses with ETS funding below). The Enhanced Training Support is extended to local employees of companies that are registered or incorporated in Singapore with at least 30% local shareholding being held by Singapore Citizens (SCs) or Singapore Permanent Residents (PRs) and, hiring not more than 200 employees (at group level) or with an annual sales turnover (at group level) of not more than S$100 million). These employees must be fully sponsored by their employers to attend training. In addition, SSG will work with industry associations and agencies so that self-employed persons can also benefit from the enhanced training support through targeted programmes. Please tick:

My company is a Small and Medium Enterprise (SME) with at least 30% local shareholding and Group annual sales turnover of not more than $100 million OR Group employment size of not more than 200 employees.

My company is not a Small and Medium Enterprise (SME). Company’s Declaration 1. We declare that the information provided in this application is accurate and complete to the best of our knowledge. We

agree that any misrepresentation or omission is sufficient ground for rejecting the application. We authorize any investigation of the above information necessary for the purpose of verification.

2. We understand that it is our company’s responsibilities: - to pay to KLCII the application fee and course fee in accordance with KLCII's payment schedule in KLCII confirmation

letter / invoice / student contract. - to apply via SkillsConnect for the sponsored employee(s) according to the stipulated timeline by SSG - within 30 days

from the course start date - to claim the absentee payroll and WTS funding / ETS funding (if applicable) in SkillsConnect for the sponsored

employee(s) according to the stipulated timeline by SSG - within 120 days from the course end date. - to abide by all funding terms and conditions stipulated by SSG for the sponsored employee under the Place-n-Train

programme with reference to KLCII explanatory notes given out to the company after confirmation of sponsorship.

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3. In the event KLCII is unable to receive the SSG supported portion of the course fee due to the following, - the training grant for the sponsored employee being rejected by SSG - failing to pay the outstanding course fee to KLCII on time - the employee breaching the terms and conditions of SSG funding or ceasing to be in our employment - the employee withdrawing/deferring/transferring from the course or not completing the course by the stipulated

course end date

We guarantee and confirm that we will pay to KLC International Institute Pte Ltd the consumed course fees* * Consumed course fees are calculated based on this formula: Total Course Fees / No. of hours X No. of hours consumed. If fees paid in advance is more than consumed course fees, there will be no refund of course fees

4. (i) We agree to cooperate with KLCII for any employer survey related to the sponsored employee or the course. (ii) We understand that SSG/WSG, or its appointed auditor or nominated representatives may contact the company representative directly to obtain information deemed necessary for the purposes of conducting effectiveness survey or audits in relation to the Programme.

Signature :

Name of Company’s Representative

:

Designation :

Company Stamp :

Date :

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(O) PERSONAL DATA PROTECTION ACT (PDPA) CONSENT FORM 个人资料保护法(PDPA)同意书

I 我,

(NAME AS PER NRIC AND NRIC NO./ PASSPORT NO.) (姓名和身份证号/护照号码)

hereby authorize, agree and consent to allow KLC International Institute Pte Ltd and its related companies, affiliates, agents/ third party service providers (collectively “KLCII”) to:

特此同意 授权智源教育学院，与其相关联的机构，以及其代理方/第三方业务提供者（统称“智源教育学院”）以下

事项：

a) Collect, use, disclose, and/or process my personal data provided by me or possessed by KLCII and that I may in future provide for the purposes as stated in KLCII’s Personal Data Protection Policy which in summary includes but not limited to the following purposes:

收集、使用、公开和处理由我提供的或由智源教育学院拥有的个人信息，以及我未来可能提供的，用于智源

教育学院个人信息保护协议项下用途的个人信息。上述用途包括但不局限于以下：

Respond to my enquiries and provide me with marketing and promotional information relating to courses,

products, and/or services that KLCII may be marketing or offering, now or in the future; and

回复我的咨询以及在将为我提供智源教育学院课程、教学产品以及相关服务的宣传信息；和

Process my application and provide me with information related to administering and/or managing my

relationship with KLCII.

处理我的申请并为我提供智源教育学院行政管理相关信息。

b) I wish /do not wish (please select) to receive marketing, advertising and promotional information from KLC International Institute via email/text message/telephone call. 我愿意/不愿意 (请选) 通过 电邮/短信/电话方式接收智源教育学院所发出的营销、广告和促销信息。

c) This consent overrides my registration with the Singapore Do-Not-Call Registry regardless of order of registration.

此批准表效力优先于我的新加坡 Do Not Call (DNC) Registry 注册，无论两者注册时间先后。

I hereby represent and warrant that I am the user and/or subscriber of the above telephone number(s) provided, and that I have read and understood the above provisions. 我认可我是以上电话号码的使用者，而且我已阅读并理解以上各项条款。

:

Signature 签字 :

Date 日期 :

NOTE: Even if you do not sign or complete this form, please note that KLCII reserves its right to send a specified fax/text message to your Singapore telephone number, if there is an ongoing relationship between KLCII and you and the purpose of the message is related to the subject of the ongoing relationship. 注：只要您仍是智源教育学院的学生，且联系的目的与维持该学生身分相关，即使您未填写并签署此表，智源教育学院仍有权使用您的新加坡电

话号码与您联系。

For withdrawal of consent, the request can be sent to KLCII Data Protection Officer either via email to dpo@klc.edu.sg or letter mailed to KLC International Institute Pte Ltd, 587 Upper Serangoon Road, Crestar Building, Singapore 534564 如欲撤销批准，请将申请通过邮件发至 dpo@klc.edu.sg 或寄信至智源教育学院，587 Upper Serangoon Road, Crestar Building, Singapore 534564 智源

教育学院信息保护部负责人收.