2015

APPLICATION FORM FOR A TAIWAN SCHOLARSHIP

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.

Please check.
Which type of scholarship are you applying for?
Undergraduate Scholarship
Master Scholarship
Doctoral Scholarship
1. PERSONAL DATA
a.NAME

Title Mr./Mrs./Ms.

Please

Surname Last name

photograph taken within the

attach

recent

last 3 months.

Given Name(s)

Chinese Name
b. CITY and COUNTRY OF
BIRTH .

c. NATIONALITY

*Note: If one or both of your parents was an ROC national at the time of your birth,
you are an ROC national as well and therefore not eligible to apply.
FATHER

d. PARENTS
INFORMATION

e. CONTACT
INFORMATION

MOTHER

Name :

Name :

Nationality :

Nationality :

Place of Birth :

Place of Birth :

Permanent Address
Mailing Address (If different from above)
Telephone

E-mail

Cell phone :
-1-

f. SEX

g. MARITAL STATUS

Male Female

Single Married

h. DATE of BIRTH

(Day Month Year ):

i. PAST RESIDENCE in

Never ; Yes, from

(dd/mm/yr) to
(dd/mm/yr).
reason for residence :

TAIWAN
j. Taiwan Scholarship/

None ; Yes, from

Huayu Enrichment

(dd/mm/yr) to

(dd/mm/yr);

Type(s) of Scholarship Awarded:

Scholarship Award
History /
k. Others Scholarship

None ; Yes, from

Award History

m. CHRONIC DISEASES

Excellent Good

IN CASE OF AN
EMERGENCY

Fair

None

n. CONTACT PERSON,

(dd/mm/yr);

Type(s) of Scholarship Awarded:

l. HEALTH CONDITION

(dd/mm/yr) to

Yes Please specify

Name :

Relationship :

Address :
Telephone :

E-mail :

Cell phone :

2. LANGUAGE PROFICIENCY

-2-

LANGUAGE

READING

COMPREHENSION

PROFICIENCY

WRITING

SPEAKING

Excellent

Good

Fair

Excellent

Good

Fair

Excellent

Good

Fair

Excellent

Good

Fair

CHINESE
ENGLISH
(Other, please state)

3. EDUCATIONAL BACKGROUND
Level

Name of Institution

Country &City

Period of Enrollment

Secondary
Education
Undergraduate Level
Education
Graduate Level
Education

4. REFERENCES ( )
Name

Position

Telephone , E-Mail or Mailing Address

5. PREVIOUS EMPLOYMENT (Use one line for each position)

Position

Company/Organization

Period of Employment

Responsibilities

-3-

6. PRESENT EMPLOYMENT
a. COMPANY/
ORGANIZATION

c. From

b. POSITION

d. CONTACT
INFORMATION

Address
Telephone

Fax

e. TYPE OF
ORGANIZATION

Govt. Ministry/
Agency

Locally-owned
Enterprise

Handphone :
E-mail

University/

Govt./State-owned

Institution

Enterprise

Joint Venture International

NGO

Enterprise

f. PRESENT
DUTIES &
YEARS OF
EMPLOYMENT

7. UNIVERSITY/DEPARTMENT, YOU PLAN TO ATTEND IN TAIWAN

The University should be listed on the Taiwan Scholarship Cooperative Universities List
-4-

University/ College and department:

-5-

8. PLEASE BRIEFLY STATE YOUR STUDY PLAN WHILE IN TAIWAN

9. DECLARATION: I declare that:

I am neither concurrently an ROC national, nor an overseas compatriot of the ROC;
I am not currently undertaking studies in Taiwan for the same educational level as the scholarship type for
which I am applying;
I am not applying for this scholarship as an exchange student resulting from an agreement signed between
my home institution and any Taiwan university/college;
The information I have given on this application is complete and accurate to the best of my knowledge.

10.CHECK LIST

Application Form with Photo

A copy of Indonesia Passport

A copy of the highest degree and academic transcripts

A copy of admission application materials to Taiwan Scholarship Cooperative Universities

A copy of a language proficiency certificate

Two letters of reference signed and sealed en envelopes. Photo copies and email
submissions of letters of recommendation will not be considered.

Applicants Signature

Date

_____ /_____/_____

-6-