附件三

教育部華語文獎學金申請表
Application Form for ROC (Taiwan) Ministry of Education 
Huayu Enrichment Scholarship 
2012-2013
 
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 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 出生城市及國別 	  		
c. NATIONALITY國籍 	*Note: If you are an overseas Chinese student, or hold a valid R.O.C. passport, you are not eligible to apply.

d. CONTACT INFORMATION 
聯絡地址、電話、
電子郵件 	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   婚姻狀況  	  □ Single單身     □ Married 已婚 	
g. DATE OF BIRTH  生日 	  (Day日／Month 月／Year 年):                      	
h. PAST RESIDENCE in TAIWAN 
  曾否居住台灣 	□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 	□  None無     
□  Yes有─Please 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 電子郵件: 	

2. LANGUAGE PROFICIENCY語言能力                
LANGUAGE
PROFICIENCY
語言能力	COMPREHENSION聽	READING 讀	WRITING 寫	SPEAKING 說	
CHINESE	Excellent 優	Good良	Fair 可	Excellent 優	Good良	Fair 可	Excellent 優	Good良	Fair 可	Excellent 優	Good良	Fair 可	
ENGLISH													
Other 
 (please state)													

3. EDUCATIONAL BACKGROUND 教育背景           
Level 程度 	Name of Institution 校名 	Country/City 
地點 	Period of Enrollment 修業年限 	
Secondary  
Education 中學 	 	 	 	
Undergraduate Level Education 
大學 	 	 	 	
Graduate Level Education 
研究所 	 	 	 	
4. REFERENCES 推薦單位 (人) 資料 
Name 姓名 	Position職務 	Phone, E-Mail or Mailing Address電話及郵電地址 	

5. PREVIOUS EMPLOYMENT 工作經歷 (Use one line for each position)  
Position  職務 	Company/Organization 
機構名稱 	Period of Employment 服務期間 	 Responsibilities  
工作說明 	

 	 	 	 	

6. PRESENT EMPLOYMENT 現職狀況 
a. COMPANY/ ORGANIZATION 
  機構名稱 	        	
b. POSITION  職稱 	 	c. From起始日期 	
d. CONTACT   INFORMATION 聯絡資訊 	Address 地址： 
Tel 電話：                           Cell phone:  
Fax 電傳：                           E-mail 電子郵件： 	
e. TYPE OF ORGANIZATION  
機構種類 	□ 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
□  NGO Enterprise  非政府機構        	

7. LANGUAGE CENTER WHERE YOU PLAN TO ATTEND IN TAIWAN擬就讀之語文中心 
 
University-affiliated language center: 	

8. BRIEFLY STATE YOUR STUDY PLAN WHILE IN TAIWAN請簡述在台讀書計畫 
 	
9. DECLARATION:  
I declare that: The information I have given on this application is complete and accurate to the best of my knowledge. 

 Applicant’s Signature                                  Date                                
                                                       _____ /_____/_____