TETO in Indonesia

2017
APPLICATION FORM FOR A TAIWAN 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.

Please check.

Which type of scholarship are you applying for?

Undergraduate Scholarship
Master Scholarship
Doctoral Scholarship

1. PERSONAL DATA

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

SurnameLast name photograph taken within the

last 3 months.
Given Name(s)

Chinese Name

b. CITY and COUNTRY OF

BIRTH .
c. NATIONALITY
*Note: If one or both of your parents was an ROC national at the time of your birth,
you are an ROC(TAIWAN) national as well and therefore not eligible to apply.
FATHER MOTHER

d. PARENTS Name : Name :

INFORMATION Nationality : Nationality :
Place of Birth : Place of Birth :

e. CONTACT Permanent Address

INFORMATION
Mailing Address (If different from above)

Telephone E-mail

Cell phone :

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f. SEX Male Female

g. MARITAL STATUS

Single Married
h. DATE of BIRTH (Day Month Year ):

i. PAST RESIDENCE in Never ; Yes, from (dd/mm/yr) to (dd/mm/yr).

TAIWAN reason for residence :

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

Huayu Enrichment
Type(s) of Scholarship Awarded:
Scholarship Award
History /
k. Others Scholarship None ; Yes, from (dd/mm/yr) to (dd/mm/yr);
Award History
Type(s) of Scholarship Awarded:

l. HEALTH CONDITION

Excellent Good Fair

m. CHRONIC DISEASES
None

Yes Please specify

n. CONTACT PERSON, Name : Relationship :

IN CASE OF AN
Address :
EMERGENCY

Telephone : E-mail :

Cell phone :

2. LANGUAGE PROFICIENCY

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COMPREHENSION
LANGUAGE READING WRITING SPEAKING

PROFICIENCY
Excellent Good Fair Excellent Good Fair Excellent Good Fair Excellent Good Fair

CHINESE

ENGLISH

(Other, please state)

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

Secondary
Education
Undergraduate Level
Education
Graduate Level
Education

4. REFERENCES ()

Name Position Telephone , E-Mail or Mailing Address

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

Company/Organization Period of Employment Responsibilities

Position

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6. PRESENT EMPLOYMENT

a. COMPANY/

ORGANIZATION

b. POSITION
c. From

Address
d. CONTACT
INFORMATION Telephone Handphone :

Fax E-mail

Govt. Ministry/ University/ Govt./State-owned

e. TYPE OF Agency Institution Enterprise
ORGANIZATION
Locally-owned Joint Venture International NGO

Enterprise Enterprise

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f. PRESENT
DUTIES &
YEARS OF
EMPLOYMENT

7. UNIVERSITY/DEPARTMENT, YOU PLAN TO ATTEND IN TAIWAN

University/ College and department:

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8. PLEASE BRIEFLY STATE YOUR STUDY PLAN WHILE IN TAIWAN

9. DECLARATION: I declare that:

I am neither concurrently an ROC national, nor an overseas compatriot of the ROC;

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

I am not applying for this scholarship as an exchange student resulting from an agreement signed between
my home institution and any Taiwan university/college;

The information I have given on this application is complete and accurate to the best of my knowledge.

10.CHECK LIST
Application Form with Photo
A copy of Indonesia Passport
A copy of Kartu Keluarga
A copy of the highest degree and academic transcripts
A copy of admission application materials to Taiwan Scholarship Cooperative Universities
A copy of a language proficiency certificate
Two letters of reference signed and sealed en envelopes. Photo copies and email
submissions of letters of recommendation will not be considered.

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Applicants Signature

Date

_____ /_____/_____

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