1、- 1 - 臺灣獎學金申請表臺灣獎學金申請表臺灣獎學金申請表臺灣獎學金申請表( ( (範例範例範例範例) ) ) 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 approp
2、riate 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，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， 申請人可自行以同款紙張加頁申請人可自行以同款紙張加頁說說明。明。 Please check. 請選以下選項請選以下選項 Which type of scholarship are you applying for? Undergraduate Scholarship 大學獎學金大學獎學金 Master Sc
3、holarship 碩士獎學金碩士獎學金 Doctoral Scholarship 博士獎學金博士獎學金 Do you need to attend a Chinese Language Enrichment Program (The LEP program must be undertaken during the first year)? Yes No (If “yes”, please fill in the name of the language center for item 7 on page 4 and apply for admissions to a degree prog
4、ram for the 2011 academic year.) 1. PERSONAL DATA 個人基本資料個人基本資料 a.NAME 姓名 姓名 Title 稱謂：稱謂： Mr./Mrs./Ms. Surname（ （Last name）姓：）姓： Given Name(s) 名：名： Chinese Name 中文姓名：中文姓名： b. CITY and COUNTRY OF BIRTH 出生出生.城市及城市及 國別國別 Please attach a recent photograph taken within the last 3 months. 最近三個月相片最近三個月相片 c.
5、 NATIONALITY 國籍 國籍 *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. FATHER 父父MOTHER 母母 d. PARENTS INFORMATION 家長資料家長資料 Name 姓名姓名: Nationality 國籍國籍: Place of Birth 出生地出生地: Name 姓名姓名: Nationality 國
6、籍國籍: Place of Birth 出生地出生地: (For official use only) Application No. 教育部教育部 外交部外交部 國科會國科會 甲表（新申請者用）甲表（新申請者用） Form A (For new applicants only) - 2 - e. CONTACT INFORMATION 聯絡地址、電話、電子聯絡地址、電話、電子 郵件郵件 Permanent Address 永久地址：永久地址： Mailing Address (If different from above)郵寄地址：郵寄地址： Telephone 電話：電話： E-mail
7、 電子郵件：電子郵件： Cell phone 手機手機: f. SEX 性別 性別 Male 男男 Female 女女 g. MARITAL STATUS 婚姻狀況婚姻狀況 Single 單身單身 Married 已婚已婚 h. DATE of BIRTH 生日生日 (Day 日日Month 月月Year 年年): i. PAST RESIDENCE in TAIWAN 居住臺灣居住臺灣 Never 否否; Yes, from (dd/mm/yr) to (dd/mm/yr).是，起迄日期是，起迄日期 reason for residence 居住事由居住事由: j. Taiwan Schol
8、arship/ Huayu Enrichment Scholarship Award History 臺灣獎學金臺灣獎學金/華華 語文獎學金受獎紀錄語文獎學金受獎紀錄 None 無無; Yes, from (dd/mm/yr) to (dd/mm/yr);是，起迄日期是，起迄日期 Type(s) of Scholarship Awarded: k. HEALTH CONDITION 健康狀況健康狀況 Excellent Good Fair l CHRONIC DISEASES 慢性病慢性病 None 無無 Yes 有有Please specify 請指明：請指明： m. CONTACT PER
9、SON, IN CASE OF AN EMERGENCY 緊急事件聯絡人緊急事件聯絡人 Name 姓名姓名: Relationship 關係關係: Address 地址地址: Telephone 電話電話: E-mail 電子郵件電子郵件: Cell phone 手機手機: - 3 - 2. LANGUAGE PROFICIENCY 語言能力語言能力 COMPREHENSION 聽聽 READING 讀讀WRITING 寫寫SPEAKING 說說LANGUAGE PROFICIENCY 語言能力語言能力 Excellent 優優 Good 良良 Fair 可可 Excellent 優優 Goo
10、d 良良 Fair 可可 Excellent 優優 Good 良良 Fair 可可 Excellent 優優 Good 良良 Fair 可可 CHINESE ENGLISH (Other, please state) 3. EDUCATIONAL BACKGROUND 教育背景教育背景 Level 程度程度 Name of Institution 校名校名 Country I am not currently undertaking studies in Taiwan for the same educational level as the scholarship type for whic
11、h 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. Applicants Signature Date _ /_/_
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