教育部华语文奖学金申请表.doc

教育部華語文獎學金申請表 Application Form for Ministry of Education Huayu Enrichment Scholarship2011-12 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. Surname（Last 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 c. NATIONALITY國籍 *Note: If one or both of your parents were an ROC national at the time of your birth, you are an ROC national as well and therefore not eligible to apply. d. CONTACT INFORMATION 聯絡地址、電話、電郵 Permanent Address永久地址： Mailing Address (If different from above)郵寄地址： Telephone電話： E-mail電子郵件： Cell phone: e. SEX性別 □ Male 男　 □ Female女 f. MARITAL STATUS 婚 □ Single單身 □ Married 已婚 g. DATE OF BIRTH 生日 (Day日／Month 月／Year 年): h. PAST RESIDENCE in TAIWAN□Never 否; □Yes, from (dd/mm/yr) to (dd/mm/yr);是，起迄日期; 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 無; □Yes, from (dd/mm/yr) to (dd/mm/yr);是，起迄日期。 Type(s) of Scholarship Awarded: j. HEALTH CONDITION 健康狀況 □ Excellent □ Good □ Fair k. ANY CHRONIC DISEASES 慢性病 □ No無 □ YesPlease 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 郵: 2. LANGUAGE PROFICIENCY語言能力 LANGUAGE PROFICIENCY 語言能力 COMPREHENSION聽 READING 讀 WRITING 寫 SPEAKING 說 Excellent優 Good良 Fair可 Excellent優 Good良 Fair可 Excellent優 Good良 Fair可 Excellent優 Good良 Fair可 CHINESE E