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ETS Scholarship Program

Application & Questionnaire for TOEFL® Test Takers
This form is designed to collect information about your background, interests, academics, demonstrated leadership, and career plans. Your answers to
these questions will be used only in connection with your application for the program and will be reviewed by an independent scholarship selection
committee of education professionals.
All responses must be provided in ENGLISH. This form is provided as an Adobe Acrobat (.PDF) file – it is highly recommended that you save this file
to your hard drive before proceeding. Please enter your responses directly into the form using the fields provided. Remember to save your work
frequently by clicking the “Save” button in the toolbar (or File > Save in the menus). When you are ready to submit your application, print a single
copy and send it, along with the required supporting documents, to the ETS Global address provided for your country on the last page of this
application.
ZAPPLICANT INFORMATIONZ
LEGAL NAME

Last/Family Name First/Given Name MI

FULL POSTAL ADDRESS

City Province (if applicable) Postal Code Country

HOME/LANDLINE TELEPHONE NUMBER (INCLUDE COUNTRY & CITY CODE) MOBILE TELEPHONE NUMBER (INCLUDE COUNTRY & CITY CODE)

E-MAIL ADDRESS GENDER DATE OF BIRTH
Female
Male / /
Day Month Year

ZTEST DETAILSZ

TOEFL Test Date: / / TOEFL Total Score: ETS ID Number:
Day Month Year

ZEDUCATION/STUDY ABROAD PLANSZ
In which country will you United Kingdom Australia
pursue your academic study? Canada My home country When do you plan to begin your study? /
(Check all that apply) United States (I am not planning to study abroad) Month Year
Other (specify):
What is your anticipated graduation date? /
Month Year
At what level of study are you? Undergraduate Postgraduate
List all institutions to which you have applied, your intended course of study, and your most current application status.
Note: If you are studying abroad and are selected as a scholarship recipient, you will be required to provide an acceptance letter from an accredited university that is an official TOEFL
Institution by June 1, 2012.
University Major/Course of Study Status of Admission

~1~

(University clubs.) Please define any acronyms. including your secondary education. Activity Dates of Participation Awards or Honors ~2~ . etc.Please briefly explain why you have decided to study in the country/countries listed on the previous page. Name of Award or Honor Granting Organization/Institution Type Date Received Academic Honor Award Academic Honor Award Academic Honor Award Academic Honor Award Academic Honor Award Academic Honor Award Academic Honor Award Academic Honor Award ZEXTRACURRICULAR ACTIVITIESZ List activities in which you have participated during the last three years. Grade/Position Dates Attended Qualification Institution Major(s)/Subject(s) with % marks From To ZHONORS & AWARDSZ Please list all academic honors and awards you have earned in the past three years. sports. student government. (150 word limit) ZACADEMIC BACKGROUNDZ Please list all academic qualifications attained. performing arts. Please include your current institution. publications. along with the supporting details requested below.

hospital volunteer. Choose one. activities. (75 word limit) ZFUTURE GOALSZ Based on your current achievements and interests. and work experience. internships. outreach programs. cultural activities. (150 word limit) ~3~ . detail your responsibilities. etc. and explain the significance of your contribution to the organization. both in your career and in your community. (150 word limit) List all part-time jobs/internships (including summer employment) you have held in the last three years.List community agencies or organizations in which you have participated without pay during the last three years. Dates Employed Position & Responsibilities Organization/Institution From To Of all your courses. describe the kind of work that you plan to be doing in 10 years. (Religious groups. which one did you find most rewarding or personally satisfying? Explain why.) Name of Agency or Organization Kind of Activity Dates of Participation # of Hours per week per year per week per year per week per year per week per year per week per year Please explain how you have demonstrated a leadership role on one or more of the activities or organizations cited in either of the previous tables.

 If you are planning to study abroad. Please provide a plan to encourage students to pursue a higher education degree. ETS may decide not to offer you a scholarship. your portfolio will remain in active status during the period that the scholarship is in force. ETS may withdraw the offer of a scholarship. unless you are certain that there will be no impediment to you securing a visa or entry clearance to study. ZPRIVACY STATEMENTZ All materials submitted to support an application in the scholarship program are used only in the selection process. or to withdraw or terminate a scholarship if it has been awarded. If you are not named as a scholarship recipient. ~4~ . your portfolio will also be retained for one year. (600 word limit) ZTERMS & CONDITIONSZ  All information provided in your application and associated documents submitted to the ETS Scholarship Program must be accurate and truthful. not misleading. You should not make commitments. and not misrepresent or omit any facts that are relevant. and will be retained for one year after the application deadline. If ETS finds significant errors or omissions in the information you have supplied to us in the course of your application. If you are named a scholarship recipient. All records are confidential and available for reference by program management staff and will be destroyed one year after the application deadline. If for any reason you cannot obtain a visa. you must provide ETS with relevant information when you apply for the ETS Scholarship Program if there is anything that may be an impediment to securing a visa or entry clearance to study in the desired country of study (such as previous convictions or associations with terrorist organizations).ZESSAY QUESTIONZ Education can have a tremendous effect on the economic development of a country. or that you have not met all of the eligibility requirements set forth by ETS. especially commitments with financial consequences.  ETS reserves the right to withdraw the offer of any scholarship award if in its sole determination it believes that the circumstances are such that this is in the best interests of the applicant or ETS.

INDIA Applicants in JAPAN . you agree to all of the conditions and requirements set forth by ETS with regard to the ETS Scholarship Program. to be used by Educational Testing Service and its third-party service providers for purposes of the ETS Scholarship Program. Kangnam-gu. 100027 China Applicants in INDIA . No.2. TOEFL and TOEIC are registered trademarks of Educational Testing Service (ETS) in the United States of America and other countries.) PRINT THIS APPLICATION If you are studying abroad and are selected as a scholarship recipient. you will be required to provide an acceptance letter from an accredited university by June 1. PARENT/GUARDIAN must SIGN HERE. the ETS logo. a unit of Educational Testing Service. Beijing. ETS Scholarship Program SUBMIT ALL REQUIRED MATERIALS TO: StudyPlaces.com or +93 11 55 96 97 TAIWAN: service@toefl.tw or +886-2-2701-7333 JAPAN: etsscholarship@cieej. Fu-Xing S. ETS. 3 Dongsanhuan. PARENTAL CONSENT IS REQUIRED: Name of Parent or Legal Guardian (Please Print) If under age 18.2. Your application will not be considered if all the documents are not received by this deadline.com or +82-2-518-1796 INDIA: TOEFL@studyplaces.45.com. Jingumae. Korea City Air Tower.jp or +81-3-5467-5477 Administrative services for the ETS Scholarship Program are provided by Scholarship & Recognition Programs. ~5~ . and have not included any other documents.C. Sec. Phase . 10th floor.or. Applicants in CHINA . If you have any questions about the ETS Scholarship Program or application process. ETS Scholarship Program 国際教育交換協議会(CIEE)日本代表部 SUBMIT ALL REQUIRED MATERIALS TO: CIEE TOEFL Division TOEFL事業部 ETSスカラシップ係 Cosmos Aoyama B1 Floor 150-8355 5-53-67. 10665 Taipei. by signing below. ETS Global BV Korea SUBMIT ALL REQUIRED MATERIALS TO: #1007. Gurgaon 122001 Haryana. (Any documents submitted in addition to the application and your official transcripts will be discarded. Taiwan(R. All rights reserved. Block B 邮编:100027 Lucky Tower. Seoul 135-973 Korea Applicants in TAIWAN . Further. 台北市大安區復興南路二段45號2樓 2F. Copyright © 2011 Educational Testing Service. Date IF APPLICANT IS UNDER THE AGE OF 18.com 308.O.) By signing below you certify that all information contained in this application and associated documentation is accurate and true and that you explicitly consent to (and have obtained such consent from any individual whose personal information you have included as part of this application) having the information provided in this application and associated documentation. ETS Scholarship Program 北京市东三环北路3号幸福大厦B座1103室 SUBMIT ALL REQUIRED MATERIALS TO: ETS China Suite 1103.org or +86 10-68313831 KOREA: ets@commkorea. and as required by this application.ZAUTHORIZATION/CERTIFICATIONZ Please review your responses and sign your name below. No. All the documents must include your TOEFL registration number. Udyog Vihar. 2012. Student's Name (Please Print) Student's Signature Print this document and SIGN HERE. Signature of Parent or Legal Guardian Date How did you hear about the ETS Scholarship Program? Study-abroad counselor Magazine/newspaper article Internet search Email from ETS Friend/colleague Other (please specify): IMPORTANT: Your application & official transcripts must be received at the ETS Global address below no later than April 13. 2012. ETS Scholarship Program ETS台灣區代表 托福測驗獎學金計畫小組 SUBMIT ALL REQUIRED MATERIALS TO: Chun Shin Ltd. Shibuya-ku 東京都渋谷区神宮前5-53-67 コスモス青山 Tokyo Japan 150-8355 Applicants in KOREA . Rd 10665 Da-an District. I have enclosed my official transcripts with this completed application form. please contact: CHINA: toefl-scholarship@etsglobal. 159-6 Samsung-dong.