中国政府长城奖学金申请表

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湖南师范大学国际交流合作处 Office of International Exchange and Cooperation Hunan Normal University 中国湖南省长沙麓山路 36 号 410081 36Lushan Rd. Changsha, Hunan P.R.China 410081 Tel: +86-731-88872992 E-mail: study@hunnu.

1 湖南师范大学国际交流合作处 Office of International Exchange and Cooperation Hunan Normal University 中国湖南省长沙麓山路 36 号 Lushan Rd. Changsha, Hunan P.R.China Tel: Fax: 学生类型 : 层次 : 学习专业 : 学习时间 : 审批意见 : ( 以上信息由录取院校填写 The above table is only for official) 湖南师范大学外国留学生入学申请表 HUNAN NORMAL UNIVERSITY APPLICATION FORM FOR OVERSEAS STUDENTS 1. 申请人情况 /Personal Data: 姓 /Surname Name: GOWIETO 名 /Given Name: JESSICA 中文名 /Chinese name: 郭丽人国籍 /Nationality: India 出生日期 /Date of Birth : 年 /Year 1996 月 /Month 06 日 /Day 01 出生地点 / Place of Birth: 国家 /Country: India 城市 /City: Jakarta 护照号码 /Passport No.: A 过期日 Expiry date: 母语 /Native Language: Indonesian 宗教 /Religion: None 男 /Male: 女 /Female: 已婚 /Married: 未婚 /Single: 职业 /Occupation: Student 工作或学习单位 (Employer and school): Cerdas Bangsa College 家庭通信地址 /Home Address: JALN PALMERH UTARA 3 NO.29, JAKARTA BARAT 电话 /Tel: wesdrx@gmail.com 目前的联系地址 /Present Address: JALAN PLUIgT INDAH, JAKARTA UTARA 电话 /Tel: CWEFSSC@gmail.com 2 国外受教育情况 /Education Background in Home Country: 学校在校时间主修专业毕业证书及学位证书 Institutions Years Attended Fields of Study Certificates Obtained or (From/to) To Be Obtained IPEKA TOMANG 至 SCIENCE SENIOR HIGH SCHOOL 3. 国外工作经历 / Employment Record in Home Country 工作单位起止时间从事工作职务及职称 Employer Time (from/to) Work Engaged Posts Held None 4. 在华学习背景 /( Study and Work Background in China ) a) 申请人是否曾在华学习或任职 / Have you ever Studied or Worked in China 是 /YES: 否 /NO: 学习或任职单位 / Institution or Employer: Time Engaged: 无 b) 是否曾申请来华奖学金 / Have you ever applied Chinese Scholarship: 是 /YES: 否 /NO: 院校 / Institution: Time Engaged: no

2 5. 语言能力 /Language Proficiency: a) 汉语 /Chinese Proficiency: 很好 /Excellent 好 /Good 较好 /Fair 差 /Poor 不会 /None HSK 考试等级 / Level of HSK test: None b) 英语 /English Proficiency: 很好 /Excellent 好 /Good 较好 /Fair 差 /Poor 不会 /None 雅思 (IELTS) 或托福 (TOFEL) 考试成绩或其他英语水平考试成绩 / Level of IELTS (TOFEL) test or other certificates: None 可以用英语学习 /I can be taught in English: 是 /Yes: 否 /No: 6. 湖南师范大学学习计划 / Proposed Study in HNU: a) 非学历生 /Non-degree student: 本科生 /Undergraduate: 硕士研究生 /Master Student : d) 专业及其学习时间 /Major and Duration of Study: 专业 /Major: Chinese language 博士研究生 /Doctoral Candidate: 自 /From: 年 /Year 2016 月 /Month 9 至 /To: 年 /Year 2017 月 /Month 7 c) 费用来源 /Source of Funding: 自费 /Self-supporting : 交换生 / Exchange student: 奖学金生 /Scholarship student: 7. 在华事务推荐人或机构 / The Reference Contacts or Guardian for You Case in China 推荐人或监护人 / The name of reference or guardian: CERDAS BANGSA COLLEGE 陈慧娟联系地址 /Present Address: Cerdas Bangsa College Pluit Village Ruko 71-72Jl. Pluit Indah Raya Jakarta 电话 /Tel: 传真 /Fax: chenhuijuan@gmail.com 8. 申请人亲属情况 Family Members of the Applicant 姓名 Name 年龄 Age 职业 Employment 父亲 Father Taddy Antonius 45 Doctor 母亲 Mother Liana 43 Teacher 配偶 Spouse 申请人保证 /I Hereby Affirm That: 1. 申请表中所填写的内容和提供的材料真实无误 ; All information and materials given in this form are true and correct. 2. 在中国学习期间将遵守中国政府的法律和学校的规章制度 I shall abide by the laws of the government of PR. China and the regulations of the University 申请人签名 /Applicant s hand writing signature: 日期 /Date: ( 无此手写签名, 申请无效 /The application is invalid without the applicant s hand writing signature) 所附材料情况 ( 请在所附附件前划标明 )/Materials Attached (Please Indicate with in the Bracket.): 护照复印件 / A Copy of the Passport Information Page 体格检查表 / Physical Examination Form for Foreigner 无犯罪记录证明 / Non-Criminal Record Certificate 本人最后学历证书和成绩单复印件 Transcripts and Diploma of the Most Advanced Studies 高中 /High school 本科 /Bachelor s 硕士 /Master s 博士 /Doctor s HSK 证明 / HSK certificate (Required for degree candidates except for majors taught in English ) 两封教授推荐信 / Recommendation Letters from of Two Professors( (Only for graduate candidates) 经济条件证明 / Financial support statement(required for self-supporting candidates) 来华学习计划 / Study Plan in China 中国的居留许可复印件和学习文件 Copies of Former Residence Permit and Study Certificate in China. (Required for the candidates who came to china before or in china now) 注 : 无论申请人是否被录取, 上述申请材料恕不退还 Whether the candidates are accepted or not, all the application materials will not be returned.

3 Passport copy 护照

4 Foreign Physical Examination Form (Student who is in aboard) 体检表

6 Police character certificate 无犯罪记录证明

7 Please check your documents and confirm that: The full name, date of birth, gender and other information in these documents: Foreign Physical Examination Form, Police character certificate, Graduation certificate, Transcripts are the same with the passport information.

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