附件一

灣獎學金申請表(範例)
外交部臺灣獎學金申請表(範例)
APPLICATION FORM FOR THE MOFA TAIWAN SCHOLARSHIP
Applicants should fill out this application form clearly and accurately. Detailed answers are
required in order to make the most appropriate arrangements. If necessary, additional pages of the
same size may be attached. 本表請申請人詳實工整填寫，慎勿遺漏，以利配合作業，如有需要，申請人
可自行以同款紙張加頁說明.

Please check: 請選以下選項

Which type of scholarship are you applying for?

□ Undergraduate Scholarship 大學獎學金

□ Master Scholarship 碩士獎學金
□ Doctoral Scholarship 博士獎學金

Do you need to attend a Mandarin Language Enrichment Program (this must be undertaken during the
first year) (是否先修華語？華語課程必須在抵臺第一年研修 )? □ Yes □ No If Yes, please fill in the name of the
language center in part 6 on page 4

1. Personal information 個人基本資料

a. Name 姓名 Title 稱謂: Mr./Mrs./Ms. Please attach a recent

Surname (Last name)姓: LAPAIX photograph (taken within
the last 3 months).
Given Name(s) 名: Obenson
最近三個月相片

b. City and country of birth City: HINCHE. Country:HAITI

出生.城市及國別
c. Nationality 國籍
*Note: If one or both of your parents was an ROC national at the time of
your birth, you are also an ROC national and therefore not eligible to apply.
d. Parents
Father 父 Mother 母
家長資料

Name 姓名: Sonèl LAPAIX Name 姓名: Roselène MICHEL

Nationality 國籍: Haitian Nationality 國籍:Haitian
Place of birth 出生地:Thomassique Place of birth 出生地:Thomassique

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e. Contact information Permanent address 永久地址: Rue Jean Jacques Dessalines,Thomassique

聯絡地址、電話、電子郵 Mailing address (if different from above)郵寄地址:

件
Telephone 電話: +509 3440 0478 Email 電子郵件: lapaixfefe@gmail.com

Cell phone 手機: +509 3201 0745

f. Sex 性別 □ Male 男 □ Female 女

g. Marital status
□ Single 單身 □ Married 已婚
婚姻狀況

h. Date of birth (Day 日／Month 月／Year 年): 16 / 08 / 1997

生日

i. Have you ever resided □Never 否; □Yes, from (dd/mm/yr) to (dd/mm/yr).是，起迄日期

Reason for residence 居住事由:
in Taiwan?
居住臺灣
□No 無; □Yes, from (dd/mm/yr) to (dd/mm/yr);是，起迄日期
j. Have you received a
Taiwan Scholarship or Type(s) of Scholarship:
Huayu Enrichment
Scholarship before? 臺
灣獎學金/華語文獎學
金受獎紀錄
k. Health condition
□ Excellent □ Good □ Fair
健康狀況

l. Chronic diseases 慢性病 □ None 無

□ Yes 有 Please specify 請指明:

m. Contact person in case Name 姓名: Roody BALDEZ Relationship 關係: Brother
of emergency
Address 地址:Rue Jean Jacques Dessalines,Thomassique
緊急事件聯絡人
Telephone 電話:+509 4054 0977 Email 電子郵件: selempierre@gmail.com

Cell phone 手機:+509 4304 2795

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 2. Language proficiency 語言能力

Comprehension Reading Writing Speaking

Language
聽 讀 寫 說
proficiency
Excellent Good Fair Excellent Good Fair Excellent Good Fair Excellent Good Fair
語言能力
優 良 可 優 良 可 優 良 可 優 良 可

Chinese

English

Creole

3. Education and training 教育背景 Note: Highest diploma only

Qualification
School name Subject (Certificate/Diploma/ Country and place Year obtained
學校名稱 研修領域 Degree) 地點 取得證書時間
資格
Lycée Capois La High school High School Thomassique-
2019
Mort Diploma HAITI

4. References 推薦單位 (人) 資料

Name 姓名 Position 職務 Telephone, email or mailing address 電話及電郵地址

CHARLES Lafontant Director +509 4202 4858

ISIDOR Bethner Censor +509 3327 8861

5. Employment/Job experience (use one row for each position) 工作經歷

Position Company/Organization Period of employment Responsibilities

職務 機構名稱 服務期間 工作說明
Rue savane sucre de Ecole Académie D'espoir De I worked there since 2020 Teaching some kids.
Thomassique Thomassique

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 6. Language center and/or university/department which you plan to attend in Taiwan 擬就讀之語文
中心或∕及大學校院系所

University affiliated language center: Taiwan Mandarin Institute in Taipei or National Cheng Kung
University in Tainan City.

University/college and department: National Taiwan University /department of Electrical

Engineering & Computer Science or National Dong Hwa University,Chinese department of Electrical
engineering.

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RECOMMENDATIONS OF LOCAL AUTHORITY OR ORGANIZATION (e.g. Government
Agency, Educational Institute, Think Tank, International Organization, Non-governmental
Organization) 駐地推薦單位，如駐在國政府機關、教育或研究機構、智庫或非政府組織

I highly recommend Mr Obenson LAPAIX for Undergraduate program at your

scholarship program MOFA. He is one of the most exceptional students, I have encountered In
my teaching experience. I am knowing Mr Obenson LAPAIX at Calis'English Academy (CEA)
of Hinche-Haiti.

He is an active student, outgoing presence in class and self-motivate, he is very

hardworking and can work Individually. He is diligent and Intelligent. Particularly I am really
impress by his full devotion and motivation to work. Because he is a dedicate person, who is
ready to achieve his goals.He has tremendous potential to undertake research work
independently through an emphasis on self-study and self-discipline.

In short Mr Obenson LAPAIX has the ability to grasp new concepts with ease and
as an outstanding young gentleman, is showing great potentialities in academic learning. I
strongly recommend him and will appreciate your assistance in his application. If you need any
further information about this young gentleman, please feel free to contact me.

Bernard LUCIEN.

Teacher of Calis'English Academy (CEA)

Email address :bernardlucien90@yahoo.fr

Cell phone : +509 4012 1073

Responsible official: Title_______________________ Signature:__________________

Name:_____________________ Date:_____________________

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 7. Please briefly state your study plan while in Taiwan 請簡述在臺讀書計畫

My name is Obenson LAPAIX. Since I was child, I was dreaming to become an international
student. The chance to apply for MOFA scholarship in Taiwan will bring me closer to my dream and
mark a wonderful milestone in my life.

The fact that I choose to apply for the MOFA scholarship to study in Taiwan as an
international student makes me strong to realize my dream. First, when I try to find a scholarship as
an international student on Google for Haitian students. I never seen any scholarship appropriate
with my dream. One day I saw the government of Taiwan shared two scholarships <<MOFA and
ICDF>>. And then I'm becoming love these scholarships. And I saw taiwan is one of the county in the
world who takes care about international student.

As an international student.If I get this scholarship, I will be in Taiwan to study Electrical

Engineering in one of those university I mentioned. And learn Chinese language to understand all the
explication. Obey the principle of the government of Taiwan and the institution and try to respect all
of the peope.

I choose Taiwan to do my bachelor's degree for more reason.Taiwan is an advanced country.

and According to my research I can say that education in Taiwan is one of the best education in Asia.

DECLARATION: I hereby declare that:

□ The information I have provided in this document is true and accurate. I understand that
any false information will disqualify me from the program, even if it is already in progress.

□ I am not suffering from any serious disease and am not hindered by any illness or
disability.

□ I am neither an ROC national, nor an overseas compatriot of the ROC.

□ I am not currently undertaking studies in Taiwan at the same educational level as the
scholarship type for which I am applying.

□ I am not applying for this scholarship as an exchange student through an agreement signed
between an educational institution in Taiwan and an educational institution outside of
Taiwan.

□ I consent to the information provided in this application form being made available to
ROC government agencies for scholarship-related matters once I become a Taiwan
Scholarship recipient.

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Applicant’s signature

Obenson LAPAIX

Date
_____ ／_____ ／_____ Day 日／Month 月
／Year 年

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