經國管理暨健康學院

2023 年春季班入學申請表-僑外生獨招
Application Form / 2023 Fall Semester -international students
請勾選 3 個就讀學系排序 Please mark 1, 2, 3 as your first choice, 2nd choice, and 3rd choice of the
departments you are applying for.
✓ 餐旅廚藝管理系 Department of Hotel, Restaurant and Culinary Management
□ 護理系 Department of Nursing
□ 高齡照顧福祉系 Department of Senior Citizen Care and Welfare
□ 口腔衛生照護系 Department of Oral Hygiene Care
□ 觀光休閒與健康系 Department of Tourism Leisure and Health
□ 食品保健系Department of Food and Health Science
□ 幼兒保育系 Department of Early Childhood Educare
□ 美容流行設計系 Department of Cosmetology and Fashion Design
*請用英文印刷體填寫Please fill out this form in print English.

1. 英文姓名 your name in English Given

Name: MASRUR RAMADANI Family Name: SUTIKNYO

2. 中文姓名 your name in Chinese (if any) 王展民

3. 國籍 Nationality: INDONESIA 性別 gender： V □男 M V □女 F

4. 生日 Date of Birth 5. 護照號碼Passport NO: E2456772

(day) / 17 (month) / 10 (year) 2004
6. 高中校名 Name of High school (in English): SMKN 1 SEKAMPUNG

7. 畢業成績 Graduation scores：83,72

8. 畢業時間 Graduation Date: (day) / 17 (month) / 05 (year) 2023

9. Your Line ID: masrur ramadhani 電子信箱 Email Address: masrurramadhani07@gmail.com

行動電話 Mobile: +6285896798649 住家電話 Home telephone No.(Country/Area Code)

+62
通訊地址 Mailing Address: RT/RW Kel. Kec. INDONESIA
027/007 Kel. Hargomulyo Kec. Sekampung
10. 父親 / 母親 / 監護人 father or mother or guardian:
姓名Name SUTIKNYO 關係Relationship: 父子 (ayah dan anak laki2)

永久地址 Permanent Address: RT/RW Kel. Kec. INDONESIA

027/007 Kel. Hargomulyo Kec. Sekampung

行動電話 Mobile: +6285783744841 電話 Telephone No.(Country/Area Code)

+62
 11. 財力來源 Financial supports
□個人儲蓄my savings V 親人family supports □獎學金scholarship □其他other

12. 您的母語. Your first language/mother tongue INDONESIAN

13. 是否學過華文 Do you have ever learned Chinese?

V YES □NO 在哪裡學 Where did you learn Chinese?

City: school / Institute: 補習班

學多久For how long? 從來沒有 never V1-3months □4-6months □Over 6 months

14. 中文語言能力自我評估 Self evaluation of Chinese language proficiency

聽listening □優Excellent □佳good V 尚可 fair □差bad
說speakig □優Excellent □佳good V 尚可 fair □差bad
讀reading □優Excellent □佳good V 尚可 fair □差bad
寫writing □優Excellent □佳good V 尚可 fair □差bad

15. 英文語言能力自我評估 Self evaluation of English language proficiency

聽listening □優Excellent □佳good V 尚可 fair □差bad
說speakig □優Excellent □佳good V 尚可 fair □差bad
讀reading □優Excellent □佳good V 尚可 fair □差bad
寫writing □優Excellent □佳good V 尚可 fair □差bad

16. 語文能力 Language certificate

語言能力 程度/分數 取得時間
Language certificate level / score Certificate date

□ 華語文能力測驗 TOCFL (day) / (month) / (year)

托福 TOEFL □ IBT □ PBT
□ 多益 TOEIC □ 雅思 IELTS (day) / (month) / (year)
□ 其他 Others(please specify)
(day) / (month) / (year)

17. 您如何得知本校招生訊息 How did you know about the admission information of CKU? Please tick

V 1.家人/親戚 Family/relatives V 2. 朋友 Friends □3. 留學中心 Education agent

□4. 其他 other sources

申請人簽名Signature: 日期Date: 16 (day) /05 (month) /2023 (year)