TETO in Indonesia

2017
2017 Application Form for Taiwan Ministry of Education

Mandarin Enrichment Scholarship (HES)

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 .

1. PERSONAL DATA

a.NAME Title Mr./Mrs./Ms. Please attach a

SurnameLast name photograph that has been
taken within the last 3
Given Name(s) months.
Chinese Name

b. CITY and
COUNTRY OF
BIRTH

c. NATIONALITY *Note: If you are an overseas Chinese student, or hold a valid R.O.C.
passport, you are not eligible to apply.

d. CONTACT Permanent Address

INFORMATION
Mailing Address (If different from above)

Telephone E-mail

Cell phone:

e. SEX
Male Female
f. MARITAL STATUS
Single Married
g. DATE OF BIRTH (DayMonth Year ):

h. PAST
RESIDENCE in Never ; Yes, from (dd/mm/yr) to (dd/mm/yr);;
TAIWAN reason for staying in Taiwan:

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 i. Taiwan
Scholarship/
None ; Yes, from (dd/mm/yr) to (dd/mm/yr);

Huayu Enrichment Type(s) of Scholarship Awarded:

Scholarship Award
History/

j. HEALTH
CONDITION
Excellent Good Fair

k. ANY CHRONIC
DISEASES None

YesPlease specify

l. CONTACT Name: Relationship :

PERSON, IN
CASE OF AN Address:
EMERGENCY
Tel: E-mail :

2. LANGUAGE PROFICIENCY
LANGUAGE COMPREHENSION READING WRITING SPEAKING
PROFICIEN
CY

CHINESE Excelle Good Fair Excellent Good Fair Excellent Good Fair Excellent Good Fair
nt
ENGLISH
Other
(please state)

2
 3. EDUCATIONAL BACKGROUND
Level Name of Institution Country/City Period of Enrollment

Secondary
Education

Undergraduate Level Education

Graduate Level Education

4. REFERENCES ()
Position Phone, E-Mail or Mailing Address
Name

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

Position Company/Organization Period of Employment Responsibilities

6. PRESENT EMPLOYMENT

a. COMPANY/
ORGANIZATION

c. From
b. POSITION

Address
d. CONTACT
INFORMATION Tel Cell phone:
Fax E-mail

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e. TYPE OF ORGANIZATION
Govt. Ministry/ University/ Govt./State-owned Agency
Institution Enterprise

Locally-owned Joint Venture Foreign-owned

NGO Enterprise

7. LANGUAGE CENTER WHERE YOU PLAN TO ATTEND IN TAIWAN

University-affiliated language center:

8. BRIEFLY STATE YOUR STUDY PLAN WHILE IN TAIWAN

9. DECLARATION:
I declare that: The information I have given on this application is complete and accurate to the best of my knowledge.

Applicants Signature Date

_____ /_____/_____