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["澎湖縣      學年度第    學期清寒優秀學生獎學金申請書                             "]
["      （此處加蓋學校戳記或關防）"]
["學生姓名",null,"性別",null,"肄業  學校","校名"]
["申請組別","□大專組□研究所組",null," □高中職組",null,"學制  科系","年制               年級                                  系(科)"]
["身分證      字     號",null,"出生    年月日","   年   月   日",null,"入學  年月","   年      月"]
["是否享有     公費待遇","□是                         □否                                                               ",null,null,"前學期成績",{"$nulls":3},"是否為      低收入戶"]
["戶籍地址",{"$nulls":3},"操行                德育              (高中職組免填)                ",null,"學業                 智育                 ",{"$nulls":3}," "]
["連絡電話","戶籍地電話：                                                     手機號碼："]
["繳附證件","一、獎學金申請書。",null,null,"縣政府           審查意見"]
[null,"二、成績單。"]
[null,"三、戶籍證明。",null,null,"縣政府           審查小組       蓋章"]
[null,"四、低收入戶證明。"]
["申請學生","蓋    章"]
["承辦人","蓋    章"]
["校長","蓋    章"]
["  中  華  民  國      年        月      日"]
["附註：本申請書各欄均應逐項詳填.如有遺漏或手續不全則不予審查"]

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