Formulaire de candidature BLC/HES


教育部華語文獎學金申請表

Application Form for ROC (Taiwan) Ministry of Education

Huayu Enrichment Scholarship 2017-2018

Application for a 3 months 6 months 9 months summer session scholarship

Please note that the selecting committee might decide to allocate shorter scholarship periods than expected by the applicant. Please state which other duration you would accept: _____ /_____ months.

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. 申請人請詳實工整填寫,慎勿遺漏,以利配合作業,如有需要,可自行以同款紙張加頁說明。

1. PERSONAL DATA 個人基本資料

a.NAME姓名

Title 稱謂: Mr./Mrs./Ms.

SurnameLast name)姓:

Given Name(s) 名:

Chinese Name 中文姓名:

Please attach a photograph that has been 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 and

PASSPORT

國籍及護照號碼

Nationality :

Passport Nber : Expiry date : (dd/mm/yr)

*Note: If you are an overseas Chinese student, or hold a valid R.O.C. passport, you are not eligible to apply.

d. CONTACT INFORMATION

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:

E-mail電子郵件:

e. SEX性別

Male Female

f. MARITAL STATUS 婚姻狀況

Single單身 Married 已婚

g. DATE OF BIRTH 生日

(Day日/Month 月/Year ):

h. PAST RESIDENCE in TAIWAN

曾否居住台灣

Never ; Yes, from to ;是,起迄日期;

(dd/mm/yr) (dd/mm/yr)

Reason for staying in Taiwan居住事由:

i. Taiwan Scholarship/ Huayu Enrichment Scholarship Award History台灣獎學金/華語文獎學金受獎紀錄

None ; Yes, from to ;是,起迄日期。

(dd/mm/yr) (dd/mm/yr)

Type(s) of Scholarship Awarded:

j. HEALTH CONDITION

健康狀況

Excellent Good Fair

k. ANY CHRONIC DISEASES

慢性病

None

Yes有─Please specify請指明:

l. CONTACT PERSON, IN CASE OF AN EMERGENCY

緊急事件聯絡人

Name姓名: Relationship 關係:

Address地址:

Tel電話: E-mail 電子郵件:


2. LANGUAGE PROFICIENCY語言能力

LANGUAGE

PROFICIENCY

語言能力

COMPREHENSION

READING

WRITING

SPEAKING

Excellent

Good

Fair

Excellent

Good

Fair

Excellent

Good

Fair

Excellent

Good

Fair

CHINESE













ENGLISH













Other

(please state)














3. EDUCATIONAL BACKGROUND 教育背景

Level 程度

Name of Institution 校名

Country/City

地點

Period of Enrollment 修業年限

Secondary

Education 中學




Undergraduate Level Education

大學




Graduate Level Education

研究所





4. REFERENCES 推薦單位 () 資料

Name 姓名

Position職務

Phone, E-Mail or Mailing Address電話及郵電地址








5. PREVIOUS EMPLOYMENT 工作經歷 (Use one line for each position)

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 INFORMATION 聯絡資訊

Address 地址:

Tel 電話: Cell phone:

Fax 電傳: E-mail 電子郵件:

e. TYPE OF ORGANIZATION

機構種類

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

私人企業 合資企業 國際公司

NGO Enterprise 非政府機構


7. LANGUAGE CENTER WHERE YOU PLAN TO ATTEND IN TAIWAN擬就讀之語文中心

From________________to __________________


8. 9 MONTHS SCHOLARSHIP APPLICANTS, please indicate:

TOCFL level passed  : __BAND_______

Year : _________ Test place : _______________________________

Test Score : Listening : ____________ Reading : __________________


9. BRIEFLY STATE YOUR STUDY PLAN WHILE IN TAIWAN請簡述在台讀書計畫



10. DECLARATION:

I declare that the information I have given on this application is complete and accurate to the best of my knowledge.

Applicant’s Signature Date

_____ /_____/_____



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