个人资料应用声明暨同意书.doc

National Central University 個人資料應用聲明暨同意書 茲同意國立中央大學國際事務處依其業務所需要之特定目的，得查詢、蒐集、處理及利用本人各項資料，提供予校內傳遞及政府部門傳遞，以為業務往來之需要。 I agree to offer my personal information to the Office of International Affairs, National Central University, for its need of gathering, processing and use as well as for forwarding the information internally and to the government departments. 本人願提供之資料包含 My personal information includes: 證件照 ID Photos 姓名(包含中文姓名) Name (including Chinese Name) 出生年月日 Date of Birth 出生地 Place of Birth 國籍 Citizenship Country 性別 Gender 學號 Student Number 護照影本/護照號碼 Photocopy of Passport/Passport Number 居留證/居留證號碼/停留證影本 Photocopy of ARC/ARC Number/Visitor Visa 入出境證影本 健保卡影本 Photocopy of Health Insurance Card 郵局局號、帳號 Post Office Account Number 戶籍地址 Permanent Address 通訊地址 Mailing Address 通訊電話 Telephone 電子信箱 Email Address 學院/系所 Department 緊急聯絡人 (包含姓名、電話、email) Emergency Contact Person 家庭狀況 Family Status 在校成績單 Academic Record 學歷證件影本 (如畢業證書) Photocopy of Diploma 僑居地身分證 (Only for Overseas Chinese Students) 分發通知書 (Only for Overseas Chinese Students) 清寒證明 Proof of Low Income (Only for Overseas Chinese Students) 自傳 Biography 同意人姓名Name：_______________________簽名Signature：____________________ 原學校：___________________________日期：_______(dd)______(mm)_______(yyyy)