2015 教育部華語文獎學金申請表

2015 Application Form for ROC (Taiwan) Ministry of Education

Huayu Enrichment 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 . 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：Ms. Please attach a

photograph that has been
Surname（Last name）姓：Pratiwi
taken within the last 3
Given Name(s) 名：Sugi months.

Chinese Name 中文姓名：苏琪 最近三個月相片

b. CITY and Sabang-Indonesia

COUNTRY OF
BIRTH 出生城市及
國別
Indonesian
c. NATIONALITY國
籍

d. CONTACT Permanent Address 永 久 地 址 ： Jurong Kebun merica Kel. Kota Bawah Barat Kec.
INFORMATION Sukakarya, Sabang

聯絡地址、電話、 Mailing Address (If different from above)郵寄地址：Komplek Perumahan Bumi Permata
lamnyong Blok L6 Desa Lamgapang Dusun Bak Liliep Kec. Krueng Barona Jaya
Lamnyong, Banda Aceh (Sumatera-Indonesia) Kode Pos: 23117
電子郵件
Telephone電話：(0652) 21902 E-mail電子郵件：sugi_pratiwi22@yahoo.com

Cell phone: +62 853 6215 4105

e. SEX性別 □ Male 男 (√) Female女

f. MARITAL STATUS (√) Single單身 □ Married 已婚

婚姻狀況

g. DATE OF BIRTH (22日／12 月／1992 年):

生日
h. PAST (√) Never 否; □Yes, from (dd/mm/yr) to (dd/mm/yr);是，起迄日期;
RESIDENCE in reason for staying in Taiwan居住事由:
TAIWAN

1
 曾否居住台灣
(√) None 無; □Yes, from (dd/mm/yr) to (dd/mm/yr);是，起迄日期。
i. Taiwan
Scholarship/ Type(s) of Scholarship Awarded:
Huayu Enrichment
Scholarship Award
History台灣獎學金/
華語文獎學金受獎
紀錄
□ Excellent (√) Good □ Fair
j. HEALTH
CONDITION

健康狀況

k. ANY CHRONIC (√) None無

DISEASES
□ Yes有─Please specify請指明：
慢性病

l. CONTACT Name姓名: Bachtiar A. Madjid, BA Relationship 關係: My Father

PERSON, IN
CASE OF AN Address地址: Jurong Kebun merica Kel. Kota Bawah Barat Kec. Sukakarya, Sabang
EMERGENCY
Tel電話: +62 852 6060 7629 E-mail 電子郵件:
緊急事件聯絡人

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

2
 3. EDUCATIONAL BACKGROUND 教育背景
Level 程度 Name of Institution 校名 Country/City Period of Enrollment 修業年限
地點
Secondary Senior High School No. 1 Sabang 2007 - 2010
Education 中學

Undergraduate Level Education Faculty of Law, Syiah Banda Aceh 2010 - 2014
大學 Kuala University

Graduate Level Education - - -

研究所

4. REFERENCES 推薦單位 (人) 資料

Name 姓名
Prof.Dr.Adwani,SH.,M.Hum
Dr. A. Rani Usman, M.Si
Position職務
The Professor in International
Law Department, Faculty of
Law, Syiah Kuala University
Director of Board of Mandarin
Education Coordination Aceh
Phone, E-Mail or Mailing Address電話及
郵電地址
+62 813 6083 8166
Email address: adwani_fh@yahoo.co.id
+62 852 8154 0018
Email address: araniusman@yahoo.co.id

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

Position 職務 Company/Organization Period of Employment 服務期間 Responsibilities
機構名稱 工作說明

6. PRESENT EMPLOYMENT 現職狀況

School of Women and Human Rights Aceh
a. COMPANY/
ORGANIZATION

機構名稱
Member c. From起始日期
b. POSITION 職稱
February, 2015

Address 地址：Jl. Residen Danu Broto N0.7 Geuceu Kayee Jato, Banda Aceh
d. CONTACT
INFORMATION 聯絡資訊 Tel 電話：- Cell phone: -
Fax 電傳：- E-mail 電子郵件：flower_aceh@yahoo.com

3
e. TYPE OF ORGANIZATION
□ Govt. Ministry/ □ University/ □ Govt./State-owned Agency政府
機構種類 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:

Chinese Language Division, Language Center College of Liberal Arts, National Taiwan
University

8. BRIEFLY STATE YOUR STUDY PLAN WHILE IN TAIWAN請簡述在台讀書計畫

My name is Sugi Pratiwi, 22 years old female. I have just graduated from International Law Department,
Faculty of Law, Syiah Kuala University, Banda Aceh, Indonesia with GPA 3,81 (Cum Laude in scale 1-4).
Furthermore, I really like learning languages, and Chinese language was the language that I learnt besides
English language. I was very interested with Chinese language from drama and music when I was in Senior High
School. According to me, Taiwan is the best country for anyone who would like to increase Chinese language
ability as me, because as I know the Chinese language that is used in Taiwan is the standard Chinese language
and has not changed. It means the society in Taiwan is still keeping and preserving their culture . So, I want to
explore more about it and of course about Taiwan cultures, natures, education, neighbohood, etc.
Finally, I am sure that I am capable to master all of the subject matter in Chinese Language Division,
Language Center College Of Liberal Arts, National Taiwan University. I really hope my application will be
received by you and I will be happy to provide any additional information that you may need.  

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

16 / Maret / 2015