Voter Registration Form

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Sep 15, 2016 - (Chinese). Part II: Submission of Voter Registration Form(s) (to be completed by the Authorised Person of
Registration Deadline 5pm, 15 September 2016 Fax : 2884 3302 / 3791 2878 Email: [email protected]

Form VR 2016 Nomination of Representatives of Arts Interests for the Hong Kong Arts Development Council (HKADC) (2016 Nomination Exercise)

Voter Registration Form for Eligible Arts Organisations IMPORTANT NOTICE: This voter registration form comprises four parts and shall be completed in BLOCK LETTERS by the eligible arts organisation. The enclosure shall be completed and signed by members/employees of eligible arts organisations applying for voter registration together with their personal correspondence address AND submitted through the eligible arts organisation. Members/employees failed to register in this Phase WILL NOT be eligible for participation in the 2016 Nomination Exercise. Each applicant for voter registration can only apply through ONE eligible arts organisation and register as voter for ONE arts interest only. Applications shall be made in respect of the same arts interest, or ONE OF the successfully registered arts interests of the eligible arts organisation concerned. Failing this, the registration process cannot be proceeded and the applicant(s) concerned cannot be registered as voter(s). Please fill in ONE ENCLOSURE FOR EACH voter registration application. Please read the Guidelines for Registration before completing this registration form. For details of the 2016 Nomination Exercise, please visit: www.voteforhkadc2016.hk, or contact the Nomination Agent [Note 1] at 3791 2286 or 3791 2032. Part I: Particulars of the Eligible Arts Organisation (to be completed by the Authorised Person [Note 2] of the arts organisation) 1.

Name of the Organisation:

(English) (Chinese)

Part II: Submission of Voter Registration Form(s) (to be completed by the Authorised Person of the arts organisation) We enclose herewith (please fill in the number of voter applications enclosed) –

-

copies of voter registration form(s) at Enclosure for consideration. (Please prepare separate copies of Enclosures for completion by members/employees)

Note 1: Instinctif Partners (Hong Kong) Limited has been appointed by the Home Affairs Bureau as the Nomination Agent of the 2016 Nomination Exercise. Note 2: The Authorised Person shall be authorised by the eligible arts organisation by virtue of Part IV of this registration form to handle all matters relating to the voter registration of the arts organisation in the 2016 Nomination Exercise.

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Part III: Declaration (to be completed by the Authorised Person of the arts organisation) 1. I declare that the information given in this registration form and enclosures is correct and the application(s) for voter registration has/have fulfilled the eligibility requirements set out in the Guidelines for Registration. 2. I confirm that our member(s)/employee(s) applying for voter registration in this Nomination Exercise has/have given consent to the application(s) made and has/have been informed that any false information willfully given or the withholding of any material information will result in their disqualification from participation in this Nomination Exercise. 3. I am authorised by the Organisation and hereby agree to produce upon the request of the Nomination Agent documentary proof to confirm the membership / employment record(s) of the member(s)/employee(s) applying for voter registration and their membership period/ employment history with the Organisation. 4. I am authorised by the Organisation and hereby consent to the release of information given herewith (together with the enclosures) to the Government and its authorised agencies for verification and purposes relating to this Nomination Exercise. I also confirm that our member(s)/employee(s) applying for voter registration in this Nomination Exercise has been informed and given consent to the release of information for the said purpose.

Signature

:

Name of Authorised Person

:

Surname (English): Given Name (English): *Dr/Mr/Mrs/Ms/Miss (* Please delete as appropriate) Surname (Chinese): Given Name (Chinese):

Position Held

:

Tel. No.

:

(Daytime): (Mobile):

E-mail Address

:

Chop of Organisation

:

Date

:

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Part IV: Organisation Authorisation (to be completed by arts organisation’s Responsible Person)

The Organisation, ___________________________________________, (name of organisation) hereby authorises ________________________ (name of authorised person) ____________________ (HKID no.), being the ___________________________ (position of authorised person in the Organisation) of this Organisation, to handle all matters relating to the voter registration made or to be made by this Organisation for the 2016 nomination of representatives of arts interests for the Hong Kong Arts Development Council. Such matters include but are not limited to : (a)

provision of consent on behalf of the Organisation to the release of information given herewith (together with the enclosures) in the course of this Nomination Exercise to the Government and its authorised agencies for verification and other purposes relating to this Nomination Exercise.

(b)

production upon request of the Home Affairs Bureau or its Nomination Agent documentary proof to confirm the membership/employment record(s) of the Applicant(s) concerned and their membership period/employment history with the Organisation.

[For a body corporate, this letter is to be signed by its duly authorised signatory who (i) is a director of the body corporate; or (ii) any person duly authorised in a board resolution of the body corporate; for an unincorporated organisation, it is to be signed by a representative duly authorised in (i) its constitution; or (ii) any other document provided by the organisation [Note 3].]

Signature

:

Name of the Responsible Person

:

Position in Organisation

:

Chop of Organisation

:

Date

:

Note 3: Please provide a certified true copy of the document to the Nomination Agent of the 2016 Nomination Exercise, i.e. Instinctif Partners (Hong Kong) Limited.

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Personal Information Collection Statement A.

B.

Purpose of Collection 1.

Personal data collected pursuant tothis registration form and its enclosure(s) will be used by the Home Affairs Bureau (HAB) or its appointed Nomination Agent for purposes related to the 2016 nomination of representatives of arts interests for the Hong Kong Arts Development Council.

2.

Any personal data provided will be handled in accordance with the Personal Data (Privacy) Ordinance (Cap. 486).

3.

The provision of personal data and other related information pursuant to this registration form and its enclosure(s) is voluntary. However, if adequate and accurate data are not provided, the HAB and its Nomination Agent may not be able to process such applications for voter registration in this Nomination Exercise.

Transfer of Information 4.

C.

Where necessary, the information provided by the eligible arts organisation and applicants for voter registration may also be provided to other authorised departments/organisations/ persons for the purposes as stated in paragraph A(1) above.

Access to / Correction of Personal Data 5.

Data subjects have a right to request access to and correction of their personal data provided in this registration forms and the enclosure(s) in accordance with the Personal Data (Privacy) Ordinance (Cap. 486).

6.

The Nomination Agent of the HAB will retain the personal data and other information collected during this Nomination Exercise. After this Nomination Exercise, all such data and information will be transferred to the Home Affairs Bureau. Requests for making access to and/or correction of personal data in this registration form and its enclosure(s) should be addressed to : (a)

the Nomination Agent (before 28 December 2016): Instinctif Partners (Hong Kong) Limited 26/F, Two Chinachem Plaza, 68 Connaught Road Central, Hong Kong Ms Phoebe Sou Tel No. : 3791 2286 Ms Sandy Cheung Tel No.: 3791 2032 Email : [email protected] Fax No. : 2884 3302 / 3791 2878

(b)

the Home Affairs Bureau (on or after 28 December 2016): Executive Officer II (Culture)1 Culture Division (1) Home Affairs Bureau 13/F, West Wing, Central Government Offices, Tim Mei Avenue, Tamar, Hong Kong Tel No.: 3509 8056 Fax No.: 2802 4893

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Form VR - Enclosure 2016 Nomination of Representatives of Arts Interests for the Hong Kong Arts Development Council (HKADC) (2016 Nomination Exercise) Voter Registration Form for Eligible Arts Organisations - Enclosure [Completed by members/employees of eligible arts organisations applying for voter registration] IMPORTANT NOTICE: This part should be completed in BLOCK LETTERS by members/ employees of eligible arts organisations applying for voter registration. Please read the Guidelines for Registration before completing this form. Completed registration forms MUST be submitted through the eligible arts organisation. Each applicant can only apply through ONE eligible arts organisation and register as voter for ONE registered arts interest of the organisation concerned. This form should be signed by the applicant together with his/her personal correspondence address. Failing the above, the registration process cannot be proceeded and the applicant concerned cannot be registered as voter for the 2016 Nomination Exercise. Part I: 1.

Particulars of the Applicant (Please put a “” in the appropriate boxes below)

Name of the Applicant (MUST be the same as shown on the HKID Card)

(English) Surname:

*Dr/Mr/Mrs/Ms/Miss

Given Name: (Chinese) Surname: Given Name: 2.

HKID No.:

(

3.

Personal Correspondence Address:

4.

Tel. No.: (Daytime)

)

(Mobile)

(The applicant □ wishes / □ does not wish to receive SMS messages from the Nomination Agent Note 1 for purposes related to this Nomination Exercise ) 5.

E-mail address:

6.

Please choose the means to receive nomination information:



Mail /



E-mail (Please tick one only)

(* Please delete as appropriate) Note 1: Instinctif Partners (Hong Kong) Limited has been appointed by the Home Affairs Bureau as the Nomination Agent of the 2016 Nomination Exercise.

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7.

I □ agree / □ disagree to release my personal information to the candidates of the Nomination Exercise (including name, registered arts interest, and correspondence address or email address). Subject to my agreement, I understand that my personal information will be released to candidates for purposes related to this Nomination Exercise.

Part II: 8.

Particulars of Organisation

I am an eligible



member /



(Please put a “” in the appropriate boxes below) employee of the following eligible arts organisation:

English name: Chinese name: 8.1

If you have joined the organisation mentioned in Item 8 above as a member/employee for less than one year (as at 29 March 2016) but have, prior to joining the said organisation, been a member/employee of other eligible arts organisation(s), please fill in the following details and provide the relevant membership/employment record(s) together with this form: English name of organisation: Chinese name of organisation: Duration and nature of membership/employment:

7.

I wish to apply as voter in this Nomination Exercise for the arts interest my organisation had successfully registered for (Please put a “” in one box only): Arts Administration

Chinese Opera (Xiqu)

Film Arts

Arts Criticism

Dance

Literary Arts

Arts Education

Drama

Music

Visual Arts

Part III: Declaration: I hereby declare that the information given in this form is correct and I have fulfilled the eligibility requirements set out in the Application Guidelines. I understand that any false information willfully given or the withholding of any material information will result in their disqualification from participation in this Nomination Exercise. I have been briefed by my organisation the Personal Information Collection Statement including the purpose of collection of personal information and consent to the release of information given herewith to the Government and its authorised agencies for verification and purposes relating to this Nomination Exercise.

Applicant’s signature: Applicant’s name:

_____________________________________ _____________________________________

2016 HKADC Nomination Exercise (Form VR- Enclosure)

Date:

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