财团法人中华民哈佛大学同学会奖学金基金会.docVIP

PAGE 3PAGE 1財團法人中華民國哈佛大學同學會獎學金基金會獎助學金申請表HARVARD CLUB OF THE REPUBLIC OF CHINA SCHOLARSHIP APPLICATION FORM姓 名 Name中 文Chinese英 文 別 號English Alias (please print)請貼照片Photograph出生日期Birth Date年 齡 Age籍 貫Birth Place性 別 Sex國民身分證 統一編號婚姻狀態Marital Status電話號碼 (日) (夜) Telephone傳 真： E-mail：Fax地址（請用中文填寫）Address家庭狀況（包括父母、配偶、兄弟姊妹、子女）Give particulars respecting nearest living relatives (Parents, spouse, brothers, sisters, etc.)姓 名 Name親屬關係 Relation年 齡 Age 地 址 Address (in Chinese)職 業　　Occupation 上列家屬中須由申請人供養者Is anyone of the above dependent on you for support? If so, who?是否負債??請說明債權人姓名，負債原因及程度Are you in debt? _____If so, to whom, to what extent and for what reason?教 育 程 度 Education學 校 名 稱 及 地 點 Name and Location of School在 學 期 間Period Attended學 位Degree主 修 科 目Major Course高 中 High School大 學Undergraduate其 他 Other在校成績總平均Undergraduate and Graduate Grade Point Average:學術或職業上之榮譽Have you received any academic or professional honors? (please specify)語文或方言Language and dialects written and spoken是否服兵役？ 何時退役？Have you completed mandatory military service for the R.O.C.? If so, when? ?????????是否曾牽涉任何刑事、民事或犯罪案件，如有，請詳述Are you currently involved in any civil of criminal litigation? ______________If yes, give particulars工 作 經 歷 Employment Record任 職 期 間Period Covered 僱 主 名 稱 Name of employing Agency工 作 性 質 Nature of Work薪 津 Salary離 職 原 因Reason for Leaving本獎學金以外之其他財務來源Please specify your planned means of financial support during your period of study (e.g. parents, savings, scholarship, etc.)列舉三位人士以為參考資詢，以教授或專業人員為佳（請勿列舉親戚）Give three references acquainted with you through school or work. (Do not give names of relatives)姓 名 Name地 址 Address (in Chi