活化历史建筑伙伴计划.docx

1、活化历史建筑伙伴计划香港非政府機構申請支援四川地震災區重建工作信託基金Applications by Hong Kong Non-Government Organizationsfor the Trust Fund in Support of Reconstruction in the Sichuan Earthquake Stricken Areas申請表格Application Form1. 填寫本申請表格前請先細閱申請撥款指引。Please read the Guide to Application carefully before completing this application

2、 form.2. 申請機構如欲申請超過一個援建項目，必須就每個項目分開填寫申請表格。If an applicant wishes to apply for more than one reconstruction support work item, it should complete one application form in respect of each item. 3. 若有關援建項目由兩個或以上香港非政府機構合作推行，有關機構之間須指定其中一個機構爲代表，以申請機構身份填寫本表格，並提供有關資料。If the reconstruction support work is to

3、be organized by more than one Hong Kong non-government organization, the organizations concerned should select among themselves one representing organization to complete this application form，and provide the required information in its capacity as the Applicant herein. 4. 此表格可用中文或英文填寫（建議申請機構盡量選擇以中文填

4、寫，以方便基金與內地相關部門的溝通）。This form may be completed in either Chinese or English. (We suggest that the application form be completed in Chinese as far as possible to facilitate communication with the concerned Mainland authorities.) 5. 如表格不敷應用，請另紙書寫。Please attach additional sheet(s) if more space is requi

5、red.援建項目名稱Reconstruction Support Work Item申請機構ApplicantI. 申請機構及内地合作夥伴資料Particulars of the Applicant and Mainland PartnerA.申請機構資料Details of Applicant 中文名稱Name in Chinese英文名稱 Name in English 地址Address通訊地址(如與上方不同)Correspondence Address (if different from the above)網址（如適用）Website (if any)傳真號碼 Fax no.聯絡人

6、Contact person姓名 Name:職位 Post:電話號碼Tel. No:電郵E-mail address:B.申請機構内地夥伴資料Details of Applicants Mainland Partner中文名稱Name in Chinese英文名稱（如適用） Name in English (if any) 地址Address通訊地址(如與上方不同)Correspondence Address (if different from the above)網址（如適用）Website (if any)傳真號碼 Fax no.聯絡人Contact person姓名 Name職位 Po

7、st電話號碼Tel. No.電郵E-mail addressC.註冊資料Registration Information申請機構已根據稅務條例第88條獲認可為慈善機構及信託團體。請在合適方格內以“X”符號表示。The Applicant is an approved charitable institution and trust of a public character under section 88 of the Inland Revenue Ordinance. Please indicate in the appropriate box with a cross “X” mark.

8、 是*Yes *申請中*Application in progress*申請機構已根據以下條例註冊* :The Applicant is registered under the following ordinance * : 公司條例The Companies Ordinance公司註冊編號Company Registration Number:社團條例The Societies Ordinance其他條例Other Ordinances請註明Please specify:* 請夾附有關的證明文件。Please attach the related documentary proof.D.四

9、川省政府的同意 (請詳閱申請撥款指引第3及4段)。請在合適方格內以“X”符號表示。Consent by Sichuan Provincial Government (Please read Paragraphs 3 and 4 of the Guide to Application carefully). Please indicate in the appropriate box with a cross “X” mark.申請機構已就本申請表内建議,與四川省政府認可的部門或機構建立合作夥伴關係，並就建議的援建項目取得四川省政府港澳事務辦公室的同意。The Applicant has est

10、ablished partnership relation with recognized authority or institute recognized by the Sichuan Provincial Government with regard to the proposed reconstruction support project, and the proposed project herein has been consented by the Hong Kong and Macao Affairs Office of the Sichuan Provincial Gove

11、rnment. 是*Yes *申請中*Application in progress* 請夾附有關的證明文件。Please attach the related documentary proof.此部分只適用於由兩個或以上香港非政府機構合作推行的項目。 This part only applies if the proposed project involves more than one Hong Kong non-government organization.E.其他合作的香港非政府機構Information of other involved Hong Kong non-govern

12、ment organisations 如有需要，可自行複印下列表格。Please reproduce the following table if necessary.中文名稱Name in Chinese英文名稱 Name in English 地址Address通訊地址(如與上方不同)Correspondence Address (if different from the above)網址（如適用）Website (if any)傳真號碼 Fax no.聯絡人Contact person姓名 Name職位 Post電話號碼Tel. No.電郵E-mail address與申請機構的合作性

13、質和詳情Nature and details of collaboration with the applicantII. 建議項目概要（工程項目）(備註：非工程項目請填寫第III部分)Brief Description of Proposed Project （For building and construction project）（Note: for non-building and construction project, please fill in part III. ） A.項目名稱 Name of ProjectB.建議項目建設地點Location of proposed

14、facilityC.項目建設性質(例如原址重建、維修加固、新建，如適用，請描述原有設施現狀)Nature of Project (Such as in situ reconstruction, repairing and reinforcing existing facility, new construction. If applicable, please describe the existing condition of original facility.) D.建設内容 (請列出詳細内容。如適用，可採用以下圖表。如有需要，請延續此表。) Scope of Works (Please

15、 set out the details. May adopt the following table if applicable. Extend it if necessary.)設施 Facility位置 Location數量 Quantity建築面積 CFA(平方米 M2)1. 例如：標準課室教學大樓xx樓至xx樓xxxx 平方米2. 例如：圖書館教學大樓xx樓xx3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. E.理由（包括受惠人數和如何使目標對象受惠）Justifications for the project (Including

16、the number of target beneficiaries and how the target beneficiaries will be benefited.)F.建設工期及初步施工時間表（以主要工作里程碑為基礎，(如有需要，請延續此表)。Duration of works and preliminary implementation timetable (With reference to key milestones. Please extend this table if necessary).整體建設工期：xx個月Overall project duration: xx

17、months主要工作里程碑Key Milestones時間表Timetable1. 20xx年xx月至20xxx年xx月(month)/200x to (month)/20xx 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. G.建設標準 (例如按照國家標準xxx級建設) Standard of facility (Such as xxx level in accordance with national standard.)H技術顧問名單(如有)Names of Technical Advisors (if any)I工程費用預算 （以當日價格標示。

18、請盡可能提供細項估算。可參考以下圖表。如有需要，請延續此表。）Total Project Estimate (In money-of-the-day prices. Please provide detailed breakdown as far as possible。 May adopt the following table format as appropriate. Extend it if necessary)細項Items詳情Details預計成本Estimated Cost(HK$ 000)1. 拆卸工程及工地清理工作Demolition and site clearance2

19、. 建築工程Building works3. 屋宇裝備Building services4. 渠務和外部工程Drainage and external works5. 家具及設備Furniture and equipment6. 擬備招標文件及合約管理顧問費Consultants fee for tender documentation & contract administration7. 工地監管顧問費Consultants fee for site supervision8. 其他(例如保險費等)，請註明：Others (e.g. insurance premium, etc.), pl

20、ease specify:9. 應急費用Contingencies總計TotalJ.財務可行性 （請註明擬向基金申請資助的款額，以及其他已確定的資金來源或擬進行的財務安排）Financial Viability (Please specify the amount of funding support from the Trust Fund applied for, other secured sources of funding support, and planned financial arrangements.) K.可持續性（請説明日後經常性開支的安排）Sustainability

21、(Please describe how the recurrent expenditure involved will be met after commencement of operation.)K.已進行的前期工作Preparatory work doneL. 命名。如申請機構打算為此項目設施命名，請提供相關詳情（例如建議的項目命名名稱，捐款人士或機構資料及捐款金額等）Name-after proposal.(If the Applicant wishes to name-after the facility in question, please specify (e.g. the

22、naming of the item after the donor, and the amount of contribution, etc.)III. 建議項目概要（非工程項目）(備註：工程項目請填寫第II部分)Brief Description of Proposed Project （non-building and construction project）（Note: for building and construction project, please fill in part II. ） A.項目名稱 Name of ProjectB.項目的性質和内容 (包括推行計劃、監察

23、及評估機制、應變措施、機構可提供的管理支援及其他增值建議。請盡量提供詳細資料）Nature and scope of project (Including implementation plans, monitoring and evaluation mechanism, contingency plans, management support and other value-added proposals. Please provide details as far as possible.)C.理由（包括受惠人數、如何使目標對象受惠）Justifications for the proj

24、ect (Including the number of target beneficiaries and how the target beneficiaries will be benefited)D.實施時間表(如有需要，請延續此表)。Implementation timetable (Please extend this table if necessary.)整體實施時間：xx個月Overall project duration: xx months工作Action時間表Timetable1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. E.費用預算（包括

25、人手預算、資歷、薪酬及其他開支，以當日價格標示。 請盡可能提供細項估算）Total Project Estimate (Including staffing/manpower requirement, qualifications, remuneration and other cost in money-of-the-day prices. Please provide detailed breakdown as far as possible.) 細項Items詳情Details預計成本Estimated Cost(HK$ 000)1. 2. 3. 4. 5. 6. 7. 總計TotalF

26、. 財務可行性（請註明擬向基金申請資助的款額，以及其他已確定的資金來源或擬進行的資金安排）Financial Viability (Please specify the amount of funding support from the Trust Fund applied for, other secured sources of funding support, and planned financial arrangements.) G.可持續性（請説明項目完成後經常性開支的安排（如適用）Sustainability (Please describe how the recurrent

27、 expenditure involved will be met after completion of the proposed project (if applicable).)H.已進行的前期工作Preparatory work done.IV. 申請機構資料Information of the ApplicantA.歷史及宗旨請提交機構組織章程細則或典章 History and objectives Please provide memorandum or constitution, if applicable.History and objectivesB.提供的主要服務Core services providedC.主要經費來源Major source(s) of funding support D.組織體制及管理能力Institutional set up and management capabilitiesE.過去推行同類型或相關計劃的經驗及成就Past experience in organizing projects of similar or relevant nature and achievements.F.其他附加資料(例如機構在香 及四川的支援網絡)Other