臺灣獎學金申請表 Applicants in Southern California, Arizona, New Mexico, Hawaii, please submit your completed application materials to the Education Division, TECO in Los Angeles 3731 Wilshire Bl. #770, Los Angeles, CA 90010 2017 APPLICATION FORM FOR A TAIWAN SCHOLARSHIP INSTRUCTIONS: This application form should be typed and completed by the applicant. Each question must be answered clearly and completely. Detailed answers are required in order to make the most appropriate arrangements. If necessary, additional pages of the same size may be attached. 本表請申請人詳實工整填寫, 慎勿遺漏, 以利配合作業, 如有需要, 申請人自行以同款紙張加頁說明 Please check. 請選以下選項 Which type of scholarship are you applying for? Bachelor Scholarship 學士獎學金 Master Scholarship 碩士獎學金 Doctoral Scholarship 博士獎學金 1. PERSONAL DATA 個人基本資料 a. NAME 姓名 Title 稱謂 : Mr./Mrs./Ms. Surname(Last name) 姓 : First Name(s) 名 : Middle Name 名 : Chinese Name 中文姓名 : Please attach a recent photograph taken within the last 3 months. 最近三個月相片 b. CITY and COUNTRY OF BIRTH 出生. 城市及國別 c. NATIONALITY 國籍 d. PARENTS 家長資料 *Note: If one or both of your parents was an ROC national at the time of your birth, you are an ROC national as well and therefore not eligible to apply. Name 姓名 : Nationality 國籍 : FATHER 父 Place of Birth 出生地 : Name 姓名 : Nationality 國籍 : MOTHER 母 Place of Birth 出生地 : - 1 -
e. CONTACT 聯絡地址 電話 電子郵件 Permanent Address 永久地址 : Mailing Address (If different from above) 郵寄地址 : Telephone 電話 : Cell phone 手機 : E-mail 電子郵件 (school account): E-mail 電子郵件 (alternative account) (*required): FaceBook account 臉書帳戶 (*required): f. GENDER 性別 Male 男 Female 女 g. MARITAL STATUS 婚姻狀況 Single 單身 Married 已婚 h. DATE of BIRTH 生日 (Month 月 /Day 日 /Year 年 ): i. PAST RESIDENCE in TAIWAN 居住臺灣 Never 否 ; Yes, from (mm/dd/yr) to (mm/dd/yr). 是, 起迄日期 reason for residence 居住事由 : j. Taiwan Scholarship/Huayu Enrichment Scholarship (HES&TUSA &AMS)Award History 台灣獎學金 / 華語文獎學金受獎紀錄 k. PASSPORT 護照資料 None 無 ; Yes, from (mm/dd/yr) to (mm/dd/yr); 是, 起迄日期 Type(s) of Scholarship Awarded: U.S Passport No. 美國護照號碼 l. HEALTH CONDITION 健康狀況 m. CHRONIC DISEASES 慢性病 n. CONTACT PERSON, IN CASE OF AN EMERGENCY 緊急事件聯絡人 None 無 Yes 有 Please specify 請指明 : Name 姓名 : Relationship 關係 : Address 地址 : Telephone 電話 : E-mail 電子郵件 : Cell phone 手機 : - 2 -
2. LANGUAGE PROFICIENCY 語言能力 LANGUAGE PROFICIENCY 語言能力 COMPREHENSION 聽 READING 讀 WRITING 寫 SPEAKING 說 CHINESE ENGLISH (Other, please state) For applicants to not all-english programs, please enclosed a photocopy of TOCFL Level 3 (or above level) test certificate. TOCFL Test Chinese Period of Learning courses/units Average GPA Proficiency 修課年限修課堂數 / 學分中文平均成績 Test Level/Score Date/Site 中文能力 ( year to year ) / / / 3. EDUCATIONAL BACKGROUND 教育背景 Name of Institution 校名 Major/Minor 主修 / 副修 GPA 學業成績 City & State 地點 Period of Enrollment 修業年限 ( year to year ) Secondary Education 中學 Undergraduate Level Education 大學 Graduate Level Education 研究 3-1. HIGHEST OR CURRENT DIPLOMA /DEGREE EARNED 目前最高學歷 Highest or Current Education Level 最高學歷 Undergraduate 大學部 Freshman Sophomore Junior Senior Postgraduate 研究所以上 Master Degree Ph.D. Degree (Expected) Graduation Date ( 預計 ) 畢業時間 Month/Year - 3 -
4. REFERENCES 推薦單位 ( 人 ) 資料 Name 姓名 Facility 單位 Position 職務 Telephone, E-Mail or Mailing Address 電話及郵電地址 5. PREVIOUS EMPLOYMENT (Use one line for each position) 工作經歷 Position 職務 Company/Organization 機構名稱 Period of Employment 服務期間 Responsibilities 工作說明 6. PRESENT EMPLOYMENT 現職狀況 a. COMPANY/ ORGANIZATION 機構名稱 b. POSITION 職稱 c. From 起始日期 d. CONTACT 聯絡資訊 e. TYPE OF ORGANIZATION 機構種類 Address 地址 : Tel 電話 : E-mail 電子郵件 : Govt. Ministry/ University/ Govt./State-owned Agency 政府部門 Institution 大學校院 Enterprise 公營企業 Locally-owned Joint Venture Foreign-owned NGO Enterprise 私人企業合資企業 Enterprise 國際公司非政府機構 - 4 -
7. UNIVERSITY AND DEPARTMENT, WHICH YOU PLAN TO ATTEND IN TAIWAN 擬就讀之大學校院 / 系所 1. University/college and department: 2. University/college and department: 8. PLEASE BRIEFLY STATE YOUR STUDY PLAN WHILE IN TAIWAN 請簡述在臺讀書計畫 9. DECLARATION: I declare that: I am neither concurrently an ROC national, nor an overseas compatriot of the ROC; I am not currently undertaking studies in Taiwan for the same educational level as the scholarship type for which I am applying; I am not applying for this scholarship as an exchange student resulting from an agreement signed between my home institution and any Taiwan university/college; The information I have given on this application is complete and accurate to the best of my knowledge. Applicant s Signature Date / / - 5 -