formulir
2017 Application
Register Student’s
Courses
INSTRUCTIONS:
This application form should be types 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
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a.NAME姓名
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Title称谓： Mr./Mrs./Ms.
Surname（Last name）姓：
Given Name(s) 名：
Chinese Name 中文姓名：
Other name :
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Please
attach a photograph that has been taken within the last 3 months.
最近三個月相片
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b. CITY and COUNTRY OF BIRTH 出生城市及國別
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c. NATIONALITY 国籍
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d. CONTACT
INFORMATION
邮寄地址、电话、
电子邮件
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Permanent
Address永久地址：
Mailing
Address (If different from above)邮寄地址：
Telephone电话： E-mail电子邮件：
Cell
phone:
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e. SEX性別
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□ Male 男 □ Female女
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f. MARITAL STATUS 婚姻狀况
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□ Single單身 □ Married 已婚
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g. DATE OF
BIRTH 生日
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(Day日／Month 月／Year
年):
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h. MOTHER LANGUAGE 母语
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□English □Indonesia □korea □Chinese □Other ____________
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i. PAST RESIDENCE in INDONESIA
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□Never 否;
□Yes, from (dd/mm/yr) to (dd/mm/yr);是，起迄日期;
reason
for staying in Indonesia
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j. INDONESIA Scholarship/ Huayu Enrichment Scholarship Award History台灣獎學金/華語文獎學金受獎紀錄
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□None 無;
□Yes, from (dd/mm/yr) to (dd/mm/yr);是，起迄日期。
Type(s) of
Scholarship Awarded:
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k. HEALTH
CONDITION
健康狀況
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□
Excellent □ Good □ Fair
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l. ANY CHRONIC
DISEASES
慢性病
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□ None無
□ Yes有─Please specify請指明：
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m. CONTACT PERSON,
IN CASE OF AN EMERGENCY
緊急事件聯絡人
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Name姓名:
Relationship 關係:
Address地址:
Tel電話: E-mail 電子郵件:
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2. LANGUAGE PROFICIENCY語言能力
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LANGUAGE
PROFICIENCY
語言能力
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COMPREHENSION聽
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READING 讀
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WRITING 寫
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SPEAKING 說
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Excellent 優
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Good良
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Fair 可
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Excellent 優
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Good良
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Fair 可
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Excellent 優
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Good良
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Fair 可
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Excellent 優
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Good良
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Fair 可
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ENGLISH
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KOREA
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CHINESE
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INDONESIA
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JAPANESE
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OTHER
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3. EDUCATIONAL
BACKGROUND 教育背景
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Level 程度
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Name of
Institution 校名
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Country/City
地點
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Period of
Enrollment 修業年限
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Secondary
Education
中學
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Undergraduate Level Education
大學
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Graduate Level Education
研究所
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4. REFERENCES 推薦單位 (人)
資料
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Name 姓名
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Position職務
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Phone, E-Mail
or Mailing Address電話及郵電地址
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5. PREVIOUS EMPLOYMENT 工作經歷
(Use
one line for each position)
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Position 職務
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Company/Organization
機構名稱
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Period of
Employment 服務期間
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Responsibilities
工作說明
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6. PRESENT EMPLOYMENT 現職狀況
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a. COMPANY/ ORGANIZATION
機構名稱
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b. POSITION 職稱
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c. From起始日期
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d. CONTACT INFORMATION 聯絡資訊
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Address 地址：
Tel 電話： Cell phone:
Fax 電傳： E-mail 電子郵件：
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e. TYPE OF ORGANIZATION
機構種類
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□ 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
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NGO Enterprise 非政府機構
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7. LANGUAGE CENTER WHERE YOU PLAN TO ATTEND IN INDONESIA
拟就印尼之语文中心
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University-affiliated language
center:
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8.
BRIEFLY STATE YOUR STUDY PLAN WHILE IN INDONESIA请简述在印尼书计画
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9.
DECLARATION:
I
declare that: The
information I have given on this application is complete and accurate to the
best of my knowledge.
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Applicant’s Signature Date
_____ /_____/_____
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